Goal Management Training Combined With External Cuing as a Means to Improve Emotional Regulation, Psychological Functioning, and Quality of Life in Patients With Acquired Brain Injury: A Randomized Controlled Trial



      To investigate whether goal management training (GMT) expanded to include external cuing and an emotional regulation module is associated with improved emotional regulation, psychological functioning, and quality of life (QOL) after chronic acquired brain injury (ABI).


      Randomized controlled trial with blinded outcome assessment at baseline, posttraining, and 6-month follow-up.




      Persons with ABI and executive dysfunction (N=70; 64% traumatic brain injury; 52% men; mean age ± SD, 43±13y; mean time since injury ± SD, 8.1±9.4y).


      Eight sessions of GMT in groups, including a new module addressing emotional regulation, and external cuing. A psychoeducative control condition (Brain Health Workshop) was matched on amount of training, therapist contact, and homework.

      Main Outcome Measures

      Emotional regulation was assessed with the Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire, the Emotional Control subscale and the Emotion Regulation factor (Behavior Rating Inventory of Executive Function–Adult Version), and the Positive and Negative Affect subscales from the Dysexecutive Questionnaire. Secondary outcome measures included psychological distress (Hopkins Symptom Checklist-25) and QOL (Quality of Life After Brain Injury Scale).


      Findings indicated beneficial effects of GMT on emotional regulation skills in everyday life and in QOL 6 months posttreatment. No intervention effects on measures of psychological distress were registered.


      GMT is a promising intervention for improving emotional regulation after ABI, even in the chronic phase. More research using objective measures of emotional regulation is needed to investigate the efficacy of this type of training.


      List of abbreviations:

      ABI (acquired brain injury), BHW (Brain Health Workshop), BRIEF-A (Behavior Rating Inventory of Executive Function–Adult Version), CBT (cognitive behavioral therapy), DEX (Dysexecutive Questionnaire), ED (executive dysfunction), EF (executive function), GMT (goal management training), QOL (quality of life)
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        • Stuss D.T.
        Functions of the frontal lobes: relation to executive functions.
        J Int Neuropsychol Soc. 2011; 17: 759-765
        • Lezak M.
        Neuropsychological assessment.
        3rd ed. Oxford Univ Pr, New York1995
        • Cicerone K.D.
        • Giacino J.T.
        Remediation of executive function deficits after traumatic brain injury.
        NeuroRehabilitation. 1992; 2: 12-22
        • Knight D.T.
        • Stuss D.T.
        Prefrontal cortex: the present and the future.
        in: Knight R.T. Stuss D.T. Principles of frontal lobe function. Oxford Univ Pr, New York2002: 573-597
        • Chan R.C.
        • Shum D.
        • Toulopoulou T.
        • Chen E.Y.
        Assessment of executive functions: review of instruments and identification of critical issues.
        Arch Clin Neuropsychol. 2008; 23: 201-216
        • Damasio A.C.
        • Carvalho G.B.
        The nature of feelings: evolutionary and neurobiological origins.
        Nat Rev Neurosci. 2013; 14: 143-152
        • Draper K.
        • Ponsford J.
        Cognitive functioning ten years following traumatic brain injury and rehabilitation.
        Neuropsychology. 2008; 22: 618-625
        • Ylvisaker M.
        • Feeney T.
        Construction of identity after traumatic brain injury.
        Brain Impair. 2000; 1: 12-28
        • Fasotti L.S.
        • Spikman J.M.
        Cognitive rehabilitation of central executive disorders.
        in: Brouwer W.H. van Zomeren A.H. Berg I.J. Bouma J.M. de Haan E.H. Neuropsychological rehabilitation: a cognitive approach. Boom, Amsterdam2002: 107-123
        • Hart T.E.
        • Evans J.
        Self-regulation and goal theories in brain injury rehabilitation.
        J Head Trauma Rehabil. 2006; 21: 142-155
        • McDonald B.C.
        • Flashman L.A.
        • Saykin A.J.
        Executive dysfunction following traumatic brain injury: neural substrates and treatment strategies.
        NeuroRehabilitation. 2002; 17: 333-344
        • Sohlberg M.M.
        • Mateer C.A.
        Effectiveness of an attention-training program.
        J Clin Exp Neuropsychol. 1987; 9: 117-130
        • Medd J.T.
        • Tate R.L.
        Evaluation of an anger management therapy programme following acquired brain injury: a preliminary study.
        Neuropsychol Rehabil. 2000; 10: 185-201
        • Hart T.
        • Brockway J.A.
        • Fann J.R.
        • Maiuro R.D.
        • Vaccaro M.J.
        Anger self-management in chronic traumatic brain injury: protocol for a psycho-educational treatment with a structurally equivalent control and an evaluation of treatment enactment.
        Contemp Clin Trials. 2015; 40: 180-192
        • Cattran C.
        • Oddy M.
        • Wood R.
        The development of a measure of emotional regulation following acquired brain injury.
        J Clin Exp Neuropsychol. 2011; 33: 672-679
        • Cole P.M.
        • Michel M.K.
        • Teti L.O.
        The development of emotion regulation and dysregulation: a clinical perspective.
        Monogr Soc Res Child Dev. 1994; 59: 73-100
        • Dams-O'Connor K.
        • Gordon W.A.
        Integrating interventions after traumatic brain injury: a synergistic approach to neurorehabilitation.
        Brain Impair. 2013; 14: 51-62
        • Draper K.
        • Ponsford J.
        • Schönberger M.
        Psychosocial and emotional outcomes 10 years following traumatic brain injury.
        J Head Trauma Rehabil. 2007; 22: 278-287
        • Fleming J.
        • Ownsworth T.
        A review of awareness interventions in brain injury rehabilitation.
        Neuropsychol Rehabil. 2006; 16: 474-500
        • Rath J.F.
        • Simon D.
        • Langenbahn D.M.
        • Sherr R.L.
        • Diller L.
        Group treatment of problem-solving deficits in outpatients with traumatic brain injury: a randomised outcome study.
        Neuropsychol Rehabil. 2003; 13: 461-488
        • Maki-Marttunen V.
        • Kuusinen V.
        • Brause M.
        • et al.
        Enhanced attention capture by emotional stimuli in mild traumatic brain injury.
        J Neurotrauma. 2015; 32: 272-279
        • van der Horn H.J.
        • Liemburg E.J.
        • Aleman A.
        • Spikman J.M.
        • Naalt J.V.
        Brain networks subserving emotion regulation and adaptation after mild traumatic brain injury.
        J Neurotrauma. 2016; 33: 1-9
        • Koole S.
        The psychology of emotion regulation: an integrative review.
        Cogn Emot. 2009; 23: 4-41
        • Zeman J.
        • Cassano M.
        • Perry-Parrish C.
        • Stegall S.
        Emotion regulation in children and adolescents.
        J Dev Behav Pediatr. 2006; 27: 155-168
        • Stuss D.T.
        • Benson D.F.
        The frontal lobes.
        Raven Pr, New York1986
        • Stuss D.T.
        • Shallice T.
        • Alexander M.P.
        • Picton T.W.
        A multidisciplinary approach to anterior attentional functions.
        Ann N Y Acad Sci. 1995; 769: 191-212
        • Posner M.I.
        • Raichle M.E.
        Images of mind.
        Scientific American Books, New York1994
        • Petersen S.E.
        • Posner M.I.
        The attention system of the human brain: 20 years after.
        Annu Rev Neurosci. 2012; 35: 73-89
        • Posner M.I.
        • Petersen S.E.
        The attention system of the human brain.
        Annu Rev Neurosci. 1990; 13: 25-42
        • Duncan J.
        • Seitz R.J.
        • Kolodny J.
        • et al.
        A neural basis for general intelligence.
        Science. 2000; 289: 457-460
        • Posner M.I.
        • Rothbart M.K.
        Research on attention networks as a model for the integration of psychological science.
        Annu Rev Psychol. 2007; 58: 1-23
        • Ruff H.A.
        • Rothbart M.K.
        Attention in early development: themes and variations.
        Oxford Univ Pr, Oxford1996
        • Cicerone K.D.
        • Langenbahn D.M.
        • Braden C.
        • et al.
        Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.
        Arch Phys Med Rehabil. 2011; 92: 519-530
        • Kennedy M.R.
        • Coelho C.
        • Turkstra L.
        • et al.
        Intervention for executive functions after traumatic brain injury: a systematic review, meta-analysis and clinical recommendations.
        Neuropsychol Rehabil. 2008; 18: 257-299
        • Cantor J.
        • Ashman T.
        • Dams-O'Connor K.
        • et al.
        Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization.
        Arch Phys Med Rehabil. 2014; 95: 1-9.e3
        • Spikman J.M.
        • Boelen D.H.
        • Lamberts K.F.
        • Brouwer W.H.
        • Fasotti L.
        Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life.
        J Int Neuropsychol Soc. 2010; 16: 118-129
        • D'Zurilla T.J.
        • Goldfried M.R.
        Problem solving and behavior modification.
        J Abnorm Psychol. 1971; 78: 107-126
        • D'Zurilla T.J.
        • Nezu A.M.
        Problem-solving therapies.
        in: Dobson K.S. Handbook of cognitive behavioral therapies. Guilford Pr, New York2001: 211-245
        • Cicerone K.D.
        • Mott T.
        • Azulay J.
        • et al.
        A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury.
        Arch Phys Med Rehabil. 2008; 89: 2239-2249
        • Cicerone K.D.
        Facts, theories, values: shaping the course of neurorehabilitation. The 60th John Stanley Coulter memorial lecture.
        Arch Phys Med Rehabil. 2012; 93: 188-191
        • von Cramon D.Y.
        • von Cramon G.M.
        Back to work with a chronic dysexecutive syndrome? (a case report).
        Neuropscyhol Rehabil. 1994; 4: 399-417
        • Levine B.
        • Robertson I.
        • Clare L.
        • et al.
        Rehabilitation of executive functioning: an experimental-clinical validation of goal management training.
        J Int Neuropsychol Soc. 2000; 6: 299-312
        • Spikman J.M.
        • Boelen D.H.
        • Pijnenborg G.H.
        • Timmerman M.E.
        • van der Naalt J.
        • Fasotti L.
        Who benefits from treatment for executive dysfunction after brain injury? Negative effects of emotion recognition deficits.
        Neuropsychol Rehabil. 2013; 23: 824-845
        • Levine B.
        • Schweizer T.A.
        • O'Connor C.
        • et al.
        Rehabilitation of executive functioning in patients with frontal lobe brain damage with goal management training.
        Front Hum Neurosci. 2011; 5: 9
        • Robertson I.H.
        • Garavan H.
        Vigilant attention.
        in: Gazzaniga M.S. The new cognitive neurosciences. MIT Pr, Cambridge2000: 563-578
        • Kabat-Zinn J.
        Full catastrophe living.
        Dell Publishing, New York1990
        • Grant M.
        • Ponsford J.
        • Bennett P.C.
        The application of goal management training to aspects of financial management in individuals with traumatic brain injury.
        Neuropsychol Rehabil. 2012; 22: 852-873
        • Miotto E.C.
        • Evans J.J.
        • de Lucia M.C.
        • Scaff M.
        Rehabilitation of executive dysfunction: a controlled trial of an attention and problem solving treatment group.
        Neuropsychol Rehabil. 2009; 19: 517-540
        • Novakovic-Agopian T.
        • Chen A.J.
        • Rome S.
        • et al.
        Rehabilitation of executive functioning with training in attention regulation applied to individually defined goals: a pilot study bridging theory, assessment, and treatment.
        J Head Trauma Rehabil. 2011; 26: 325-338
        • Fish J.
        • Evans J.J.
        • Nimmo M.
        • et al.
        Rehabilitation of executive dysfunction following brain injury: “content-free” cueing improves everyday prospective memory performance.
        Neuropsychologia. 2007; 45: 1318-1330
        • Manly T.
        • Hawkins K.
        • Evans J.
        • Woldt K.
        • Robertson I.H.
        Rehabilitation of executive function: facilitation of effective goal management on complex tasks using periodic auditory alerts.
        Neuropsychologia. 2002; 40: 271-281
        • Bertens D.
        • Kessels R.P.
        • Fiorenzato E.
        • Boelena D.H.
        • Fasotti L.
        Do old errors always lead to new truths? A randomized controlled trial of errorless goal management training in brain-injured patients.
        J Int Neuropsychol Soc. 2015; 21: 639-649
        • Chen A.J.
        • Novakovic-Agopian T.
        • Nycum T.J.
        • et al.
        Training of goal-directed attention regulation enhances control over neural processing for individuals with brain injury.
        Brain. 2011; 134: 1541-1554
        • Robertson I.H.
        • Levine B.
        Attention and arousal in neurorehabilitation.
        in: Stuss D.T. Knight R.T. Principles of frontal lobe function. 2nd ed. Oxford Univ Pr, New York2013: 742-749
        • Arnemann K.L.
        • Chen A.J.
        • Novakovic-Agopian T.
        • Gratton C.
        • Nomura E.M.
        • D'Esposito M.
        Functional brain network modularity predicts response to cognitive training after brain injury.
        Neurology. 2015; 84: 1568-1574
        • Stubberud J.
        • Langenbahn D.
        • Levine B.
        • Stanghelle J.
        • Schanke A.K.
        Goal management training improves everyday executive functioning for persons with spina bifida: self-and informant reports six months post-training.
        Neuropsychol Rehabil. 2014; 24: 26-60
        • Tornås S.
        • Løvstad M.
        • Solbakk A.K.
        • et al.
        Rehabilitation of executive functions in patients with chronic acquired brain injury with goal management training, external cuing and emotional regulation: a randomized controlled trial.
        J Int Neuropsychol Soc. 2016; 21: 1-17
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        • CONSORT Group
        CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials.
        BMJ. 2010; 340: c332
        • Stubberud J.
        • Langenbahn D.
        • Levine B.
        • Stanghelle J.
        • Schanke A.K.
        Goal management training of executive functions in patients with spina bifida: a randomized controlled trial.
        J Int Neuropsychol Soc. 2013; 19: 672-685
        • Baycrest Centre for Geriatric Care
        Goal Management Training Trainer's Manual.
        Baycrest Centre for Geriatric Care, Toronto2012
        • Beck A.T.
        • Alford B.A.
        Depression: causes and treatment.
        2nd ed. University of Pennsylvania Pr, Philadelphia2009
        • Becker F.
        • Kirmess M.
        • Tornas S.
        • Lovstad M.
        A description of cognitive rehabilitation at Sunnaas Rehabilitation Hospital—balancing comprehensive holistic rehabilitation and retraining of specific functional domains.
        NeuroRehabilitation. 2014; 34: 87-100
        • Wechsler D.
        Manual for the Wechsler Abbreviated Scale of Intelligence.
        Psychological Corp, San Antonio1999
        • Delis D.C.
        • Kaplan E.
        • Kramer J.H.
        • Ober B.
        California Verbal Learning Test-II.
        Psychological Corp, San Antonio2000
        • Benedict R.H.
        Brief Visuospatial Memory Test–Revised: professional manual.
        Psychological Assessment Resources, Odessa1997
        • Wechsler D.
        Wechsler Adult Intelligence Scale III, WAIS III.
        Psychological Corp, San Antonio1997
        • Conners C.K.
        Connors' CPT II Continuous Performance Test II.
        Multi Health Systems, North Tonawanda2000
        • Delis D.C.
        • Kaplan E.
        • Kramer J.H.
        Delis-Kaplan Executive Functioning System (D-KEFS).
        Psychological Corp, San Antonio2001
        • Gioia G.A.
        • Isquith P.K.
        • Guy S.C.
        • Kenworthy L.
        Behavior Rating Inventory of Executive Function: professional manual.
        Psychological Assessment Resources Inc, Lutz2000
        • Burgess P.W.
        • Alderman N.
        • Emslie H.
        • Evans J.J.
        • Wilson B.A.
        The dysexecutive questionnaire.
        in: Wilson B.A. Alderman N. Burgess P.W. Emslie H. Evans J.J. Behavioural assessment of the dysexecutive syndrome. Thames Valley Test Company, Bury St. Edmunds1996
        • Derogatis L.R.
        • Lipman R.S.
        • Rickels K.
        • Uhlenhuth E.H.
        • Covi L.
        The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory.
        Behav Sci. 1974; 19: 1-15
        • von Steinbüchel N.
        • Petersen C.
        • Bullinger M.
        • QOLIBRI Task Force
        Assessment of health-related quality of life in persons after traumatic brain injury—development of the QOLIBRI, a specific measure.
        Acta Neurochir Suppl. 2005; 93: 43-49
        • von Steinbüchel N.
        • Richter S.
        • Morawetz C.
        • Riemsma R.
        Assessment of subjective health and health-related quality of life in persons with acquired or degenerative brain injury.
        Curr Opin Neurol. 2005; 18: 681-691
        • Zald D.H.
        • Andreotti C.
        Neuropsychological assessment of the orbital and ventromedial prefrontal cortex.
        Neuropscyhologia. 2010; 48: 3377-3391
        • Roth R.M.
        • Lance C.E.
        • Isquith P.K.
        • Fischer A.S.
        • Giancola P.R.
        Confirmatory factor analysis of the Behavior Rating Inventory of Executive Function–Adult Version in healthy adults and application to attention-deficit/hyperactivity disorder.
        Arch Clin Neuropsychol. 2013; 28: 425-434
        • Donders J.S.
        • Strong C.A.
        Latent structure of the Behavior Rating Inventory of Executive Function–Adult Version (BRIEF-A) after mild traumatic brain injury.
        Arch Clin Neuropsychol. 2016; 31: 29-36
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum, Hillsdale1988
        • Roth R.M.
        • Isquith P.K.
        • Gioia G.A.
        Behavior Rating Inventory of Executive Function—Adult Version.
        Psychological Assessment Resources, Lutz2005
        • Finnanger T.G.
        • Olsen A.
        • Skandsen T.
        • et al.
        Life after adolescent and adult moderate and severe traumatic brain injury: self-reported executive, emotional, and behavioural function 2–5 years after injury.
        Behav Neurol. 2015; 2015: 329241
        • Burgess P.W.
        • Alderman N.
        • Evans J.J.
        • Emslie H.
        • Wilson B.A.
        The ecological validity of test of executive function.
        J Int Neuropsychol Soc. 1998; 4: 547-558
        • Bennett P.C.
        • Ong B.
        • Ponsford J.
        Measuring executive dysfunction in an acute rehabilitation setting: using the Dysexecutive Questionnaire (DEX).
        J Int Neuropsychol Soc. 2005; 11: 376-385
        • Truelle J.-L.
        • Koskinen S.
        • Hawthorne G.
        • et al.
        Quality of life after traumatic brain injury: the clinical use of the QOLIBRI, a novel disease-specific instrument.
        Brain Inj. 2010; 24: 1272-1291
        • Ravndal E.A.
        • Amundsen E.J.
        Mortality among drug users after discharge from inpatient treatment: an 8-year prospective study.
        Drug Alcohol Depend. 2010; 108: 65-69
        • Prigatano G.P.
        Principles of neuropsychological rehabilitation.
        Oxford Univ Pr, New York1999
        • Rueda M.R.
        • Posner M.I.
        • Rothbart M.K.
        Attentional control and self-regulation.
        in: Baumeister R.F. Vohs K.D. Handbook of self-regulation: research, theory, and applications. Guilford Pr, New York2004: 283-300
        • Tang Y.-Y.
        • Ma Y.
        • Wang J.
        • et al.
        Short-term meditation training improves attention and self-regulation.
        Proc Natl Acad Sci U S A. 2007; 104: 17152-17156
        • Chiesa A.
        • Calati R.
        • Serretti A.
        Does mindfulness training improve cognitive abilities? a systematic review of neuropsychological findings.
        Clin Psychol Rev. 2011; 31: 449-464
        • Simblett S.K.
        • Bateman A.
        Dimensions of the Dysexecutive Questionnaire (DEX) examined using Rasch analysis.
        Neuropsychol Rehabil. 2011; 21: 1-25
        • Simblett S.K.
        • Badham R.
        • Greening K.
        • Adlam A.
        • Ring H.
        • Bateman A.
        Validating independent ratings of executive functioning following acquired brain injury using Rasch analysis.
        Neuropsychol Rehabil. 2012; 22: 874-889
        • Chaytor N.
        • Schmitter-Edgecombe M.
        • Burr R.
        Improving the ecological validity of executive functioning assessment.
        Ach Clin Neuropsychol. 2006; 21: 217-227
        • Cicerone K.
        • Mott T.
        • Azulay J.
        • Friel J.C.
        Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury.
        Arch Phys Med Rehabil. 2004; 85: 943-950
        • Stubberud J.
        • Langenbahn D.
        • Levine B.
        • Stanghelle J.
        • Schanke A.-K.
        Emotional health and coping in spina bifida after goal management training: a randomized controlled trial.
        Rehabil Psychol. 2015; 60: 1-16
        • van Hooren S.A.
        • Valentijn S.A.
        • Bosma H.
        • et al.
        Effect of a structured course involving goal management training in older adults: a randomised controlled trial.
        Patient Educ Couns. 2007; 65: 205-213
        • Ben-Yishay Y.
        • Diller L.
        Handbook of holistic neuropsychological rehabilitation: outpatient rehabilitation of traumatic brain injury.
        Oxford Univ Pr, New York2011
        • Cisler J.M.
        • Olatunji B.M.
        • Feldner M.T.
        • Forsyth J.P.
        Emotion regulation and the anxiety disorders: an integrative review.
        J Psychopathol Behav Assess. 2010; 32: 68-82
        • Fischer S.
        • Trexler L.E.
        • Gauggel S.
        Awareness of activity limitations and prediction of performance in patients with brain injuries and orthopedic disorders.
        J Int Neuropsychol Soc. 2004; 10: 190-199
        • Hart T.
        • Whyte J.
        • Kim J.
        • Vaccaro M.
        Executive function and self-awareness of “real-world” behavior and attention deficits following traumatic brain injury.
        J Head Trauma Rehabil. 2005; 20: 333-347
        • Logan D.E.
        • Claar R.L.
        • Scharff L.
        Social desirability response bias and self-report of psychological distress in pediatric chronic pain patients.
        Pain. 2008; 136: 366-372
        • McCambridge J.
        • de Bruin M.
        • Witton J.
        The effects of demand characteristics on research participant behaviours in non-laboratory settings: a systematic review.
        PLoS One. 2012; 7: e39116
        • Prigatano G.P.
        • Altman I.M.
        Impaired awareness of behavioral limitations after traumatic brain injury.
        Arch Phys Med Rehabil. 1990; 71: 1058-1064