Psychological therapies for depression in older adults residing in long-term care settings.

BACKGROUND: Depression is common amongst older people residing in long-term care (LTC) facilities. Currently, most residents treated for depression are prescribed antidepressant medications, despite the potential availability of psychological therapies that are suitable for older people and a preference amongst many older people for non-pharmacological treatment approaches. OBJECTIVES: To assess the effect of psychological therapies for depression in older people living in LTC settings, in comparison with treatment as usual, waiting list control, and non-specific attentional control; and to compare the effectiveness of different types of psychological therapies in this setting. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, five other databases, five grey literature sources, and two trial registers. We performed reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was 31 October 2021. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and cluster-RCTs of any type of psychological therapy for the treatment of depression in adults aged 65 years and over residing in a LTC facility. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles/abstracts and full-text manuscripts for inclusion. Two review authors independently performed data extraction and risk of bias assessments using the Cochrane RoB 1 tool. We contacted study authors for additional information where required. Primary outcomes were level of depressive symptomatology and treatment non-acceptability; secondary outcomes included depression remission, quality of life or psychological well-being, and level of anxious symptomatology. We used Review Manager 5 to conduct meta-analyses, using pairwise random-effects models. For continuous data, we calculated standardized mean differences and 95% confidence intervals (CIs), using endpoint data, and for dichotomous data, we used odds ratios and 95% CIs. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included 19 RCTs with 873 participants; 16 parallel group RCTs and three cluster-RCTs. Most studies compared psychological therapy (typically including elements of cognitive behavioural therapy, behavioural therapy, reminiscence therapy, or a combination of these) to treatment as usual or to a condition controlling for the effects of attention. We found very low-certainty evidence that psychological therapies were more effective than non-therapy control conditions in reducing symptoms of depression, with a large effect size at end-of-intervention (SMD -1.04, 95% CI -1.49 to -0.58; 18 RCTs, 644 participants) and at short-term (up to three months) follow-up (SMD -1.03, 95% CI -1.49 to -0.56; 16 RCTs, 512 participants). In addition, very low-certainty evidence from a single study with 82 participants indicated that psychological therapy was associated with a greater reduction in the number of participants presenting with major depressive disorder compared to treatment as usual control, at end-of-intervention and short-term follow-up. However, given the limited data on the effect of psychological therapies on remission of major depressive disorder, caution is advised in interpreting this result. Participants receiving psychological therapy were more likely to drop out of the trial than participants receiving a non-therapy control (odds ratio 3.44, 95% CI 1.19 to 9.93), which may indicate higher treatment non-acceptability. However, analyses were restricted due to limited dropout case data and imprecise reporting, and the finding should be interpreted with caution. There was very low-certainty evidence that psychological therapy was more effective than non-therapy control conditions in improving quality of life and psychological well-being at short-term follow-up, with a medium effect size (SMD 0.51, 95% CI 0.19 to 0.82; 5 RCTs, 170 participants), but the effect size was small at postintervention (SMD 0.40, 95% CI -0.02 to 0.82; 6 RCTs, 195 participants). There was very low-certainty evidence of no effect of psychological therapy on anxiety symptoms postintervention (SMD -0.68, 95% CI -2.50 to 1.14; 2 RCTs, 115 participants), although results lacked precision, and there was insufficient data to determine short-term outcomes. AUTHORS' CONCLUSIONS: This systematic review suggests that cognitive behavioural therapy, behavioural therapy, and reminiscence therapy may reduce depressive symptoms compared with usual care for LTC residents, but the evidence is very uncertain. Psychological therapies may also improve quality of life and psychological well-being amongst depressed LTC residents in the short term, but may have no effect on symptoms of anxiety in depressed LTC residents, compared to control conditions. However, the evidence for these effects is very uncertain, limiting our confidence in the findings. The evidence could be strengthened by better reporting and higher-quality RCTs of psychological therapies in LTC, including trials with larger samples, reporting results separately for those with and without cognitive impairment and dementia, and longer-term outcomes to determine when effects wane.

Caring Self-Efficacy of Personal Care Attendants From English-Speaking and Non-English-Speaking Countries Working in Australian Residential Aged Care Settings.

Objectives: This study compared the caring self-efficacy between personal care attendants (PCAs) from English-speaking and non-English-speaking countries, controlling for potential sociodemographic and work-related covariates. PCAs' perceptions of their caring self-efficacy were further explored. Methods: An independent samples t-test was used to determine the mean difference in the caring self-efficacy score between the two groups. A multivariate analysis was conducted to adjust for covariates. Thematic analysis was conducted on open-ended responses. Results: The results showed that caring self-efficacy was significantly influenced by whether participants primarily spoke English at home rather than where they were born. Younger age and everyday discrimination experiences were negatively associated with caring self-efficacy. Both groups perceived that inadequate resources and experiencing bullying and discrimination reduced their caring self-efficacy. Discussion: Access to organisational resources and training opportunities and addressing workplace bullying and discrimination against PCAs, particularly younger PCAs and those from non-English-speaking backgrounds, could improve their caring self-efficacy.

Psychometric properties of the Caring Efficacy Scale among personal care attendants working in residential aged care settings.

OBJECTIVE: This study assessed the psychometric properties of the Caring Efficacy Scale (CES) among personal care attendants providing care to older residents in residential aged care settings. METHODS: This cross-sectional study was completed in Australia in 2020-2021. Confirmatory factor analysis (CFA) of the 30-item original CES (Model 1) and 28-item CES validated in registered nurses (Model 2) was conducted to assess the goodness of fit of these models in our study population. Due to unsatisfactory fit indices for both models, exploratory factor analysis (EFA) was conducted to examine the dimensionality and underlying structure of the original CES among personal care attendants. Internal consistency of the final scale and subscales identified was examined using item-total correlations and Cronbach's alpha coefficients. RESULTS: Two hundred and eighty personal care attendants participated in the study. The model fit indices such as Comparative Fit Index and Tucker Lewis Index of both models were less than 0.90, while the Standardised Root Mean Square Residual and Root Mean Square of Approximation values were greater than or equal to 0.08 and 0.06, respectively. The EFA identified a two-factor structure, and 22 items of the 30 in the original scale were retained. Item-total correlations amongst items retained in the scale and subscales were greater than 0.3. Cronbach's alpha for the abbreviated scale was 0.85, with 0.83 and 0.79, respectively, for the two subscales. CONCLUSIONS: The modified CES can be used as a robust tool to assess the self-efficacy of personal care attendants in providing care to older residents in residential aged care settings.

Caring behaviours of culturally diverse personal care attendants from the perspective of older people living in residential aged care settings.

This study aimed to determine whether older residents perceive differences in the care they receive from personal care attendants (PCAs) of similar cultural backgrounds versus those from other cultural backgrounds. The challenges encountered when receiving care from culturally diverse PCAs were also explored. A directed qualitative content analysis approach was utilised. Results showed that PCAs' personalities were perceived to have a greater impact on all aspects of care delivery than their cultural backgrounds. PCAs from other cultural backgrounds were also perceived to be more observant, pleasant, and sociable than their local counterparts, despite the communication challenges due to their limited English proficiency. This study indicates that migrant PCAs can significantly contribute to addressing workforce shortages in the aged care industry without compromising care quality, but it also highlights the need for long-term strategies to improve meaningful interaction between culturally diverse PCAs and residents and foster a positive work environment.

Factors associated with nursing students' attitudes toward older people: A scoping review.

Nursing students rate geriatric nursing poorly in career preferences, but aging populations mean more older people require access to health care. Negative attitudes held by nursing students can lead to ageism affecting the quality of care provided. The purpose of this scoping review is to summarize research findings in the published literature relating to factors associated with nursing students' attitudes toward older people, and the tools used to measure these attitudes. The Joanna Briggs Institute guide for conducting a scoping review was used. Eleven databases and search engines were searched for international peer reviewed research articles published in English between January 2000 and February 2021. Sixteen articles were included in the review. This review highlights areas for affirmative action to improve undergraduate nursing students' attitudes toward older people to prepare them to work effectively in future health care systems. Positive attitudes were associated with: senior years of study; professional values (caring, professionalism, trust); education regarding care of older adults; knowledge about aging; contact with older family members; comfort communicating with older people; and willingness to work with older people following graduation. It also identified the need for a current, nursing-specific measure of attitudes toward older people.

Evaluation of the impact of The Little Things training on personal care assistants' confidence to communicate with residents in aged care.

OBJECTIVES: To evaluate The Little Things training program, designed to assist personal care assistants (PCAs) from culturally and linguistically diverse (CALD) backgrounds to communicate more effectively with aged care residents. METHODS: This project included PCAs from residential aged care facilities (RACFs) and Certificate III students from registered training organisations (RTOs) in Melbourne, Australia. A control group (n = 18) was also included. Measures included the following: pre- and posttraining confidence to communicate and rankings of task importance; posttraining perceived change in confidence; and posttraining impacts on practice. RESULTS: Altogether, 75 PCAs and 30 RTO students participated in Intake I of the training and 31 PCAs and 34 RTO students in Intake 2. Confidence increased in The Little Things participants relative to those in the control group (ß = 0.11, T = 1.99, p = 0.05). Change did not vary by Intake or whether someone was in the RACF or RTO group, F (2, 147) = 0.58, p = 0.5; nor by sociodemographic characteristics. Most training participants (84%) thought their ability to communicate with older people would 'improve a lot' as a result of the training. Training participants also ranked the importance of duties such as 'Speaking in a friendly and informal way to older people' more highly after than before the training (p = 0.01), while little change was observed in the control group. CONCLUSIONS: The Little Things program increased training participants' confidence to communicate and shifted perceived priorities towards interacting with residents in a way that enhanced resident well-being.

A Retrospective Cohort Study of Women and Men Living with HIV, Attending an HIV Clinic in Australia.

Objectives: To compare women with men presenting with HIV to a public health HIV clinic, to identify the special characteristics and health care needs of women living with HIV in the Barwon South West region in Victoria. Methods: A retrospective cohort study of 35 women and 135 men living with HIV who attended the clinic between 2009 and 2020. Gender differences were assessed using nonparametric analyses. Results: The women were diagnosed with HIV younger than the men (mean 29.5 years vs. 36.7 years) and more were born in Africa (28.6% vs. 5.2%). More men than women presented with sexually transmittable infections (38.5% vs. 14.3%) at the time of diagnosis, and were diagnosed through a sexual health screen (37% vs. 17%). The proportions of men and women who used alcohol and other drugs (recent to their diagnosis) were similar (68.1% vs. 48.6%), and there was no difference in proportions presenting with AIDS-defining illnesses (p = 0.425), or CD4 cell count (advanced: ≤200 cells, relatively well: ≥201 cells, p = 0.241), but the women had a lower viral load (p < 0.001). Conclusions: In this study of 170 people living with HIV, nearly one-half of the men with known HIV history were diagnosed through sexual health screens, but women's HIV was mostly detected through targeted screening. Results highlight gender disparity in access to sexual health screening and assessment, including low awareness of sexual health risks for women, and endorse the view that HIV is a heterosexual sexually transmittable infection in women.

Conditions required to ensure successful detection and management of mild cognitive impairment in primary care: A Delphi consultation study in China.

Objective: Detection and management of mild cognitive impairment (MCI) in primary care has been recognized internationally as one of the strategies that can be employed to delay the development of dementia. However, little is known about what role primary care should play. This study aimed to develop a checklist of conditions necessary for successfully detecting and managing mild cognitive impairment in primary care in China. Methods: This study employed the Delphi method to establish expert consensus on the conditions required for successfully detecting and managing MCI in primary care in China. Twenty-four experts who specialized in general practice, public health, neuropsychology, or community health service management rated the importance of pre-defined conditions (44 items measuring providers' preparedness, patient engagement, and system support in line with the Chronic Care Model). The degree of consensus among the experts was measured using four indicators: median ≥ 4, mean ≥3.5, Co-efficient of Variance < 0.25, and retention in the checklist required ≥ 80% agreement with a rating of important or essential. The checklist and descriptions of the conditions were revised according to the experts' feedback and then sent out for repeated consultations along with a summary of the results of the previous round of consultations. Consensus was achieved after the second round of consultations, which was completed by 22 of the experts. Results: The experts endorsed a checklist of 47 conditions required for successful detection and management of MCI in primary care in China. These conditions were categorized into four domains: prepared general practitioners (17 items), engaged patients (15 items), organizational efforts (11 items), and environmental support (4 items). Conclusions: Successful detection and management of MCI in primary care in China requires a dedicated and competent workforce of general practitioners, as well as the engagement of patients and family caregivers. Adequate support from healthcare organizations, health system arrangements, and the broader society is needed to enable effective interactions between general practitioners and patients and efficient delivery of the services required to detect and manage MCI.

Challenges in detecting and managing mild cognitive impairment in primary care: a focus group study in Shanghai, China.

INTRODUCTION: Detection of mild cognitive impairment (MCI) is essential in slowing progression to dementia. Primary care plays a vital role in detecting and managing MCI. The chronic care model (CCM) provides effective methods to manage chronic diseases. OBJECTIVE: This study aimed to explore how MCI services are delivered in primary care in China. METHODS: Focus group interviews were conducted face to face among MCI stakeholders from six community health centres (CHCs) involved in the 'friendly community programme' in Shanghai, China. A total of 124 MCI stakeholders were interviewed, consisting of 6 groups (n=42) of general practitioners (GPs), 3 groups (n=18) of CHC managers, 4 groups (n=32) of people with MCI and 4 groups (n=32) of informal caregivers. Content and thematic analyses were performed using a combination of induction and deduction approaches. RESULTS: Three major themes emerged from the data corresponding to the CCM framework: hesitant patients, unprepared providers and misaligned environments. While the public are hesitant to seek medical attention for MCI problems, due to misunderstanding, social stigma and a lack of perceived benefits, GPs and CHCs are not well prepared either, due to lack of knowledge and a shortage of GPs, and a lack of policy, funding and information support. None of these issues can be addressed separately without tackling the others. CONCLUSION: This study combined the diverse perceptions of all the main stakeholders to detect and manage MCI in primary care settings in China. A vicious circle was found among the three interconnected CCM domains, creating a gridlock that should be addressed through a system's approach targeting all of the above-mentioned aspects.

Psychosocial modification of general self-efficacy in older adults: A restricted review.

OBJECTIVES: In recent years, the concept of general self-efficacy has increased in popularity. General self-efficacy is positively associated with quality of life and has the potential to act as a psychological buffer against adverse events and circumstances. However, due to the long-term influences that are said to shape general self-efficacy beliefs, they may be resistant to intervention, particularly within the older population. This restricted review aimed to explore whether psychosocial interventions could improve the general self-efficacy of older adults. Aspects of intervention design associated with improvements were also investigated. METHODS: A restricted review was undertaken. This included a keyword search of four major health databases (PubMed, CINAHL, PsycINFO and AgeLine). Search terms focused on general self-efficacy and the commonly used measures of this concept and were limited to the older adult population. RESULTS: In total, 848 articles were screened, with 20 studies proceeding to data extraction. The modification of general self-efficacy in older adults appears possible, with 7 out of the 20 included studies reporting improvements postintervention. Despite issues relating to the quality of included studies and the generalisability of their results, several aspects of intervention design coincided with intervention success, including intervention duration, and employing sufficiently-qualified staff. CONCLUSIONS: Future research must address the generalisability issues identified in this review. Studies comparing the effectiveness of individual- and group-based interventions, the efficacy of remote delivery platforms and the possibility for long-term transfer of any improvements are needed to contribute the high-quality data required for policy and practice decisions in this area.

Does non-implanted electrical stimulation reduce post-stroke urinary or fecal incontinence? A systematic review with meta-analysis.

BACKGROUND: Urinary and fecal incontinence are disabling impairments after stroke that can be clinically managed with electrical stimulation. AIM: The purpose of this systematic review was to determine the effectiveness of non-implanted electrical stimulation to reduce the severity of post-stroke incontinence. SUMMARY OF REVIEW: Clinical trials of non-implanted electrical stimulation applied for the purposes of treating post-stroke incontinence were searched in MEDLINE, EMBASE, CINAHL, PEDro, and CENTRAL. From a total of 5043 manuscripts, 10 trials met the eligibility criteria (n = 894 subjects). Nine trials reported urinary incontinence severity outcomes enabling meta-analysis of transcutaneous electrical nerve stimulation (TENS; five trials) and electroacupuncture (four trials). Studies provide good-to-fair quality evidence that TENS commenced <3 months post-stroke has a large effect on urinary continence (SMD = -3.40, 95% CI -4.46 to -2.34) and a medium effect when commenced >3 months after stroke (SMD = -0.67, 95% CI -1.09 to -0.26). Electroacupuncture has a large effect when administered >5 times a week (SMD = -2.32, 95% CI -2.96 to -1.68) and a small effect when administered five times a week (SMD = -0.44, 95% CI -0.69 to -0.18). Only one trial reported the effect of non-implanted electrical stimulation on post-stroke fecal incontinence. CONCLUSIONS: Published trials evaluating the effect of non-implanted electrical stimulation on post-stroke incontinence are few and heterogenous. Synthesized trials suggest that early and frequent treatment using electrical stimulation is probably more effective than sham or no treatment. Further trials measuring incontinence in an objective manner are required.

Caring self-efficacy of direct care workers in residential aged care settings: A mixed methods scoping review.

The caring self-efficacy of direct care workers in residential aged care has been explored in the literature mostly as a predictor rather than the focus of interest. This scoping review aimed to provide an overview of the existing literature on aged care workers' caring self-efficacy and factors that influence it. A systematic search was performed in six electronic databases. All primary studies were included. A total of 41 studies met the inclusion criteria. Caring self-efficacy was most often described by aged care workers as their capacity to deal with difficult situations. The self-efficacy scores of direct care workers were high across studies. Self-efficacy was positively influenced by access to resources, relationships with residents and their families, the support of supervisors and co-workers, job satisfaction, and training opportunities, and negatively affected by work pressure and burnout. Findings indicate possible avenues for intervention to improve direct care workers' self-efficacy in aged care.

Self-efficacy of direct care workers providing care to older people in residential aged care settings: a scoping review protocol.

BACKGROUND: Self-efficacy is developed through a person's interaction with his/her physical and social environment. Self-efficacy in caring is an essential attribute of care workers to develop a positive attitude towards their clients, improve work performance, and enhance job satisfaction. Care workers' self-efficacy may vary according to the context in which the care is being provided. Aged care is a multidimensional and challenging setting, and characteristics of aged care services are different from those of acute care services. The objective of this review is to give an overview of the self-efficacy of residential aged care workers in caring for older people and factors influencing their self-efficacy. METHODS: The protocol for this review is based on the Joanna Briggs Institute Reviewer's Manual for Scoping Review. A systematic search of the literature on electronic databases MEDLINE, PsycINFO, CINAHL, AgeLine, SCOPUS, and ProQuest Dissertations and Theses Global will be carried out using predefined search terms to identify relevant studies. This review will include studies that examined the self-efficacy of direct care workers in caring for older people living in residential aged care facilities. All primary studies irrespective of the study design will be included. Studies conducted to develop measures or studies with informal care workers or students as study participants will not be considered. Two reviewers will independently conduct title and abstract screening, full-text screening, and data charting. A third reviewer will resolve discrepancies, while the final decision for conflicting studies will be made by consensus within the review team. Descriptive statistics will be utilized to analyze the quantitative findings, and the result will be presented in narrative form accompanied by tables and charts. Content analysis will be carried to analyze the qualitative findings and will be presented in narrative form supported by illustrative quotations. DISCUSSION: This study will be an important source of knowledge to policymakers and aged care providers to understand the self-efficacy of aged care workers to support and enhance their self-efficacy and thereby improve their caring behaviors towards their clients. SCOPING REVIEW REGISTRATION: Joanna Briggs Institute Systematic Review Register with the title "A scoping review of factors influencing caring efficacy of direct care workers providing care to older people".

What predicts consumer experience in residential aged care? An analysis of consumer experience report data.

Objectives This study explored whether consumer experience report (CER) data from residential aged care services (RACSs) could be combined into a general factor and determined whether poor experience in RACSs could be predicted by known resident or home characteristics or sampling procedures. Methods CER data collected by structured interviews in 2018 and early 2019 were analysed using structural equation modelling and linear regression analysis. Results Data were available from 17194 interviews undertaken at 1159 RACSs. The 10 CER items loaded onto two independent factors. Bifactorial modelling indicated that items could be combined into a general factor. Controlling for state or territory, consumer experience was best predicted by home size: those in large facilities reported poorer experience than those in smaller facilities. Other significant negative predictors with small effect sizes included not being independently mobile, being male and not being randomly selected. Dementia did not predict total CER score. Conclusions The results of this study support the inclusion of people with dementia and exclusion of volunteer participants from published CERs. Further research is needed to explore why a relatively poor consumer experience is reported by people in larger homes, men and those with mobility issues. What is known about the topic? Poor experience in aged care is a persistent concern for government, individuals and aged care services. The recent Royal Commission into Aged Care Quality and Safety has identified systemic failure. Although many organisational features and processes have previously been identified as important in determining the quality of care, few studies have explored the characteristics that predict the consumer experience of residents in aged care. What does this paper add? This paper provides empirical evidence that several variables influence consumer experience in aged care, including facility size and resident sex and mobility. There is evidence that smaller facilities provide care that is perceived better by residents, and that men and people with mobility issues have worse experiences in aged care. There is a lack of clarity as to what other influences, such as facility ethos, facility location and staffing levels, may contribute to resident experience. Such clarity is important, because Australian aged care is currently facing comprehensive scrutiny, and governments are looking to ensure the safety and quality of aged care services. What are the implications for practitioners? Identifying and addressing inequities in aged care services and mitigating risks must be a priority in Australia to ensure aged care services provide safe and high-quality care. The results of this study challenge current funding structures that encourage the development of larger aged care homes, and instead suggest that better funding for smaller-sized facilities may be able to improve the experience of residents in aged care. The results also suggest that facilities and governments should attend to the experiences of specific groups, such as men and people with mobility issues.

Pastoral Care in Aged Care Settings: Role and Challenges.

This mixed methods study explored challenges faced by pastoral care workers. A development phase preceded an on-line survey completed by chaplains and pastoral practitioners (n = 40) employed by a major Australian aged care provider. The survey covered the purpose of pastoral care, key tasks and resources, current and future challenges, and participants' responses to challenges. The biggest issue was heavy demand on participants' time, due to insufficient staff and demanding organisational procedures. A commonly mentioned challenge with future implications was increasing resident acuity. Respondents were dedicated and enthusiastic, despite heavy workloads and occasional difficulty working with care staff or management.

Characteristics and effectiveness of cognitive behavioral therapy for older adults living in residential care: a systematic review.

OBJECTIVES: Cognitive behavioral therapy (CBT) for depression and anxiety for older adults living in residential aged care facilities (RACFs) needs to accommodate the care needs of residents and the circumstances of RACFs. This systematic review examines the delivery and content characteristics of these interventions, in relation to participant satisfaction, staff appraisal, uptake rate, attrition rate, and treatment effectiveness. Such a review could provide important information for the development of future CBT-based interventions. METHOD: Studies that examined the application of CBT for depression or anxiety in RACFs were identified by systematically searching a number of relevant databases. Reference lists of all included studies were examined, and citation searches on the Web of Science were conducted. Two independent reviewers were involved in screening articles and in extracting data and assessing methodological quality of the selected studies. RESULTS: Across the 18 studies included in this review, the most common therapeutic strategy was pleasant activities scheduling. Studies varied on treatment duration (2-24 weeks), number of sessions (6-24), and length of sessions (10-120 min). Residents and staff members were satisfied with the CBT interventions. The average uptake rate was 72.9%. The average attrition rate was 19.9%. Statistically significant results were reported in 8 of the 12 randomized controlled trials (RCTs). In these eight RCTs, CBT was characterized by psychoeducation, behavioral activation, and problem-solving techniques; further, the therapists in six of these studies had training in psychology. CONCLUSION: CBT interventions for depression and anxiety are acceptable to RACF residents and judged positively by staff members. Effective studies differed from non-effective studies on content and training characteristics, but not on other delivery features.

"I'm more aware now": perspectives from people with mild cognitive impairment (MCI), supporters and counsellors about the MAXCOG cognitive rehabilitation intervention.

Objectives: Cognitive Rehabilitation interventions have the potential to improve quality of life for people with MCI. We recently developed, trialled, and evaluated the use of the MAXCOG (Maximising Cognition) intervention-a very brief (four-session) face-to-face program focussing on individualised goals to improve function in daily life. Although the program assisted people reach their practical goals, we could not demonstrate broader changes to quality of life, mood, or carer burden. The aim of this study was to explore qualitatively the experiences of clients, supporters, and counsellors who participated.Method: Fifteen clients, fourteen supporters, and three counsellors were interviewed using the Most Significant Change technique. Subsequently, thirty-five narrative accounts were transcribed and subjected to thematic analysis following Braun and Clarke's (2006) model.Results: Key themes identified changes at two levels: specific changes (Putting strategies in place; and Doing it differently) and meta changes (More aware now; Facing up to life; and on top of anxiety and stress). Participants also mentioned supports and hindrances.Conclusion: The analysis provided a new perspective on the experiences of participants, supporters, and counsellors with the MAXCOG intervention, including identification of psychological changes that were not apparent from the quantitative analyses.