Family members’ and friends’ reports after standard and intensive group treatment for social communication difficulties following acquired brain injury – a mixed method approach

ABSTRACT Objective To examine family members/friends’ perception of change following standard and intensive group interactive structured treatment (GIST) for persons with social communication difficulties (SCDs). Methods A parallel mixed methods design combining data from questionnaires, the Goal Attainment Scale, and interviews. Participants Forty-nine adult (>18 years) family members/friends (69.4% female) of persons with SCDs and acquired brain injury (ABI) (cohabitating partner, 53.1%; other relatives, 30.6%; friends, 16.3%). Intervention Standard GIST consisted of 12 weekly outpatient sessions (2.5 h). Intensive GIST consisted of 4 weeks of inpatient rehabilitation (2 × 3 days/week, 2 × 4 days/week). Both treatments included 3- and 6-month follow-ups. Main outcome measures Quantitative measures (n = 49) included the following informant reports: Latrobe Communication Questionnaire (LCQ), Social Communication Skills Questionnaire-Adapted (SCSQ-A), Behavior Rating Inventory for Executive Functions-Adult version (BRIEF-A), and Goal Attainment Scale. The qualitative measure (n=9) was an interview performed at 6-month follow-up. Results Converging results were found, suggesting a perceived positive change over time for both standard and intensive GIST, with no substantial differences reported between the treatments. Conclusions Family members/friends reported improved social communication skills of the persons with SCDs following standard and intensive GIST. However, the integration of data showed the complexity of assessing SCDs and the need for further investigation.


Introduction
Social communication difficulties (SCDs) after acquired brain injury (ABI) have been found to have a devastating effect on social participation and interpersonal relationships, and they are often associated with poor psychosocial outcomes, loss of social contacts and/or employment, poor mood and loss of identity (1)(2)(3).SCDs occur when underlying cognitive, communicative, emotional, and/or physical difficulties caused by ABI affect the person's social communication skills, such as self-awareness, perspective-taking and self-monitoring, and social cognition (4)(5)(6)(7)(8).Of note, SCDs are considered a risk factor for family breakdown (1).It is well documented that the consequences of ABI affect well-being and family life for many years (1,9).In fact, 5 years after traumatic brain injury (TBI) marital breakdowns are reported for 42% of those with mild to moderate disabilities and 78% of those with severe disabilities (10).Depression and anxiety have also been reported in as many as 50% of family caregivers (1,11).Nevertheless, families are often the ones caring for and spending the most time with their injured family member after formal rehabilitation has ended (12,13).
Research investigating the efficacy of treatments for persons with SCDs is limited (4), and measures that adequately assess treatment outcomes are scant (14,15).The existing evidence suggests a holistic, context-sensitive approach to treatment that uses a combination of impairment-based interventions, functional activities, and context-supported participation in everyday life situations (16)(17)(18).To increase the participation of persons with SCDs in daily life, it has been suggested that treatment is delivered in groups with individual goal-setting (16,19,20) or that environmental support in the social network (e.g.family members/friends) of persons with SCDs is improved (18,21,22).However, few studies have directly involved family members in program design or included their perspective regarding the efficacy of treatment (1,6,(23)(24)(25).
Group interactive structured treatment (GIST) is an evidence-based context-sensitive intervention for persons with SCDs and ABI, focusing on increasing social competence (26).Importantly, in GIST, family or friend involvement is valued in promoting generalization (12,26).Specifically, the role of family members/friends in GIST is to participate and discuss home assignments and give feedback, provide motivation and support in the practice of individual goals or newly learned social skills at home (26).Previous studies have demonstrated improvement in social communication skills following GIST for persons with TBI and its feasibility while simultaneously suggesting the need for further investigation of the efficacy of GIST across other ABI-populations and delivery formats (6,(27)(28)(29).
On this basis, our group was inspired to conduct a twoarmed randomized controlled trial (RCT) investigating the efficacy of two versions of GIST: a) standard GIST delivered in an outpatient setting and b) intensive GIST delivered in an inpatient setting (4,29).The intensive inpatient format was selected based on promising results of intensive interventions for ABI found in other studies (30)(31)(32).The results from our RCT indicated improvements in social communication skills after both treatments when compared to the waitlist control, with results maintained at the 3-and 6-month follow-ups (29).There were no statistically significant differences found in the results between the two treatments, suggesting that GIST can be delivered across different treatment formats.Standard GIST has been validated in other studies with similar results (6,27,28).Intensive GIST was trialed for the first time in our study, and the results were promising (4,29,33).However, the results only represent the perspective of participants with SCDs, and the sample size was small, so further investigation is needed.
The current GIST literature primarily focuses on the efficacy of treatment from the perspective of persons with SCDs (28,29) or briefly reports findings from family members/ friends secondarily without further elaboration (6,27).This current paper presents additional data from our RCT (4,29) with a focus on family member/friend reports.There are several reasons why the perspective of family members/friends is important and requires research attention.As described, these individuals are typically the ones spending the most time with the person with SCDs, which gives them unique knowledge as a conversation partner and an opportunity to observe communication in everyday life.This places them in the position to evaluate the efficacy of treatment from the level of activity and participation as described by the World Health Organization (21,23).In addition, reduced self-awareness among persons with SCDs and ABI is often a challenge in rehabilitation and can affect long-term outcomes (34), and by including informant reports, we are able to investigate the efficacy of treatment from a different point of view.Furthermore, the perspective of family members/friends is valuable for gaining greater insight into the implementation and possible outcomes of a treatment.
Accordingly, the main purpose of this study is to address the perspective of family members/friends and their perceptions of the efficacy of standard and intensive GIST.Grounded in quantitative and qualitative data, we primarily investigate whether and how family members/ friends' perception of change is reported post training and during follow-ups.This leads to the following research questions: Do family members/friends report improvement in social communication skills following standard or intensive GIST for persons with SCDs?If so, how do the improvements reported by each intervention group compare at 6-month follow-up?

Design
In the present study, we chose a pragmatic approach and a parallel mixed methods design to study the quantitative and qualitative aspects of family members/friends' perspectives (35,36).We combined quantitative data from three informant questionnaires and one goal attainment scale with qualitative data from in-depth interviews.By integrating various types of data in our analyses, we wanted to obtain deeper insight into family members/friends' perspectives and produce more robust findings than those yielded by using only one approach (35).The study design and data collection are visually presented in Figure 1.The study was approved by the Norwegian Regional Committee of South East for Medical and Health Research Ethics (2017/1360) and registered at ClinicalTrials.gov(NCT03636399).

Inclusion criteria
The current mixed methods study was part of an RCT and was conducted at Sunnaas Rehabilitation Hospital in Norway.The recruitment began in September 2018 and ended in December 2019, and pairs of participants, consisting of persons with SCDs and one of their family members/friends, were recruited through several channels (4).See the flow diagram (Figure 2).
The study population of the RCT consisted of adults with ABI and SCDs in the chronic phase living in the southeastern part of Norway (4,29).The family members/friends were included based on two criteria: I) selected by the person with SCDs; II) committed to being the support person during treatment and follow-ups.The inclusion and exclusion criteria for participants with SCDs are listed in Supplementary file 1.After providing consent, the family member/friend was invited to take part in a preinclusion meeting with the first author, where the role of the support person was described, and voluntary written consent was obtained.
A total of 49 pairs of participants were included in the RCT, and randomly allocated to the two treatment arms (standard GIST [n = 24]; waitlist control/intensive GIST [n = 25]).One pair of participants dropped out after waitlist control before intensive GIST (n = 24) (Figure 2).

Participants
The participants in the quantitative sample included 49 family members/friends (34 women and 15 men).Some of the persons with SCDs found it difficult to find a family member/ friend to include in the study, and because of this, the relationship status differed between the pairs; the family members/ friends included cohabitating partners (53.1%), adult children (12.2%), other relatives (siblings/parents, 18.4%), friends (12.2%) and ex-partners (4.1%).
The qualitative sample was selected through purposive sampling (36), collecting in-depth information from family members/friends from one standard GIST group (n = 6) and one intensive GIST group (n = 6) in the quantitative sample.Due to practical considerations, the selection was based on two groups that had 6-month follow-up assessments the same week.However, two of the family members/friends declined to participate, and one audio recording of the interviews was lost in storage, resulting in a total of 9 participants in the qualitative sample (standard GIST [n = 6]; intensive GIST [n = 3]).The relationship status in the sample varied, including four cohabitating partners (44.4%), one sibling (11%), one parent (11%), two adult children (22.2%), and one friend (11%).

Intervention
Standard GIST was delivered once a week (2.5 h) over a period of 12 weeks in an outpatient setting.Between the weekly sessions, the pairs of participants were encouraged to go through the weekly session in the workbook, discuss the topic, and work on the home assignments together.
Intensive GIST consisted of the same 12 sessions as the standard GIST.However, the modules were delivered in a more condensed manner (4-hour daily sessions, 2 × 3 days/ week and 2 × 4 days/week) over a 4-week period.The intensive GIST participants had extended leave every weekend to go home and practice social communication in their own social environment and to discuss the topics and home assignments with their family members/friends'.More details about the content of the interventions are described in the research protocol (4) and available as Supplementary file 2 following the TiDIER format.

Data collection
The quantitative data collected covered three commonly used informant-report questionnaires: the Latrobe Communication Questionnaire (LCQ), the Social Communication Skills Questionnaire (SCSQ-A) and the Behavior Rating Inventory for Executive Functions-Adult version (BRIEF-A), as well as the Goal Attainment Scale (GAS).The quantitative data were collected at four time points (Figures 1 and 2).The qualitative data were collected via semi structured interviews conducted with a selection of family members/friends at the 6-month follow-up.Data collection was completed in June 2020.

Quantitative outcome measures (Informant-reports)
The LCQ assesses the communication ability and behavior of the person with SCD and ABI from the family members/ friends' perspective using a four-point scale: never or rarely (1), sometimes (2), often (3) and usually or always (4).A lower total score indicates fewer reported symptoms of SCDs (37).The LCQ has shown good psychometric quality in other studies and is commonly used to assess the perception of SCDs (27,28,38).The SCSQ-A (39) is a 37-item fivepoint Likert scale questionnaire addressing various communication behaviors and all aspects of GIST (40).A higher total score indicates better perceived social communication skills.The BRIEF-A (41) consists of 75 items assessing perceived executive function using a three-point scale: never a problem (N), sometimes a problem (S), and often a problem (O) (total range: 70-210), with a higher score indicating more executive dysfunction in daily life.In the GAS, family members/friends assess the goal achievement of persons with SCDs personal goals after treatment.The GAS includes personal preferences and demands and has shown strong reliability, validity, and sensitivity in other studies (42,43).
In this study, the social communication skill goals were determined by the participant with SCDs in collaboration with his or her family member/friend and the GIST-therapist (s).We used individual and predefined scales of 1-5 points for assessing goal achievement (6), and the baseline (status before treatment) was always set to 2 points in the scale, and the expected realistic goal achievement was always set to 4 points.

An illustrative example of a participant's GAS scale is as follows:
Goal: To think before I speak (so that I avoid saying inappropriate things).
(1) I will master it in 1-2 out of 10 cases.
(2) I will master it in 3 out of 10 cases (status before treatment).(3) I will master it in 4-5 out of 10 cases.(4) I will master it in 6-7 out of 10 cases (goal).
The questionnaires were completed on paper by the family members/friends in their own time without influence from the assessors.The two GIST-therapists (including the first author) carried out the GAS assessment and were not blinded to group allocation.Therefore, an additional scoring of the GAS was conducted based on audio recordings of the original scoring carried out by the person with SCDs, family member/friend, and therapist.The additional scoring was conducted by a trained research assistant blinded to group allocation and verified the original scoring with a 100% agreement.

Qualitative outcome measure
The qualitative data were collected using a semi structured interview.The family members/friends were asked to describe the social communication skills of the person with SCDs, any change after treatment, and if change had occurred, what they believed caused this change; they were also asked to describe their own experiences as a support person and their personal needs for the future.The interview guide is accessible in Supplementary file 3. The interviews were conducted in January 2020 by a trained research assistant and on one occasion, one GIST-therapist.Seven of the interviews were conducted over the telephone, and two of the interviews were performed face-to-face.

Analyses
Data analysis in this parallel mixed methods study consisted of three phases (35,36).First, we analyzed the quantitative data in terms of statistical results.Second, we analyzed the qualitative database by coding the data and collapsing the codes into broad themes and categories.In the final phase we conducted mixed methods data analyses by integrating the two datasets to explore whether the qualitative data confirmed the quantitative data (35,36).We used a side-by-side comparison approach (35), presenting the results from the quantitative and qualitative datasets separately and the mixed methods-integration between the two datasets in the Discussion.

Quantitative data analysis
A sample size of 60 pairs of participants was originally calculated for the RCT (4), but could not be achieved, resulting in a total of 49 participant pairs.Due to dropouts and COVID-19-related restrictions, only 21 of the 24 family members/ friends completed the entire standard GIST protocol, and 18 family members/friends completed intensive GIST (see Figure 2).In addition, the last follow-up assessments were conducted remotely (i.e., telehealth), resulting in an increased amount of missing data for the participants in these groups (standard GIST, n = 5; intensive GIST, n = 12).Due to the nature of the research question, the waitlist control results were not included in the present analysis.
All quantitative analyses were performed using the Statistical Package for the Social Sciences (SPSS) Version 28 (44), with p < 0.05 as the level of significance.The results were analyzed with an intention-to-treat model including all 49 family members/friends who completed pretreatment assessments.Demographic variables were described with counts and percentages or with means and standard deviations, and between-group differences were analyzed with t-tests for continuous variables.The LCQ, SCSQ-A, and BRIEF-A results were modeled over time for standard and intensive GIST using a generalized linear mixed model for repeated measures to compare the results between and within the two treatment arms.The results were analyzed with unstructured covariance matrices to estimate within-subject statistical dependencies.The fixed effects were set for group, time, and group*time interaction and included the family members/friends' relationship and sex as covariates for adjustment.The family member/ friends' GAS scores and effects were compared between the standard and intensive GIST arms, at pre-and posttreatment, and after the 3-and 6-month follow-ups using chi-square tests and the Wilcoxon signed rank test.

Qualitative data analysis
A thematic analysis (45) of the results from the semi structured interviews was completed.All interviews were audiorecorded and thoroughly orthographically transcribed by research assistants before being validated for accuracy against the audio recordings by the first author.All transcripts were organized and coded with NVivo Version 12 pro.The first author reviewed the transcripts multiple times and began reducing the data and identifying core themes and categories (45,46) before the categories were reviewed again by the first author against the coding and original transcripts to strengthen the quality of the analysis.Finally, the coding was verified by a trained research assistant, leading to some minor adjustments (e.g., clarification of individual categories and double coding) until consensus was reached.The coding into categories is operationalized with examples in Table 4.The interviews, transcripts and analysis were conducted in Norwegian, and quotes were translated into English for presentation.To protect the participants' anonymity, all the family members/friends are referred to by fictitious names.

Reliability
The first author acknowledges the potential influence of her many roles in this study as a researcher, assessor, and GIST therapist.Thus, careful attention was given to ensure that the data analysis was not affected by the researchers' preunderstanding or expectations.To compensate for this potential researcher bias, trained research assistants blinded to group allocation were used in scoring the tests, plotting the data, transcribing the interviews, and verifying the coding.Illustrative quotes from the interviews were also used in the text to highlight the voices of the family members/friends.However, the researcher's experience as a speech-language pathologist with years of experience working with persons with SCDs and ABI and the in-depth knowledge about the participants in this RCT were also considered valuable in understanding quotes from the transcripts or interpreting the data in general.

Quantitative analysis
The study sample consisted of 49 family members/friends (69.4% female) of persons with SCDs and ABI.The participants had known the persons with SCDs for 2-58 years (standard GIST: 2-58 years; intensive GIST: 2-55 years), and 79.2% of the participants in standard GIST and 72% of the participants in intensive GIST reported that they knew the person with SCDs very well.A comparison between the groups on demographic variables found a statistically significant difference in gender distribution for family members/friends with a predominance of females in intensive GIST (p=0.003).Other than this, there were no differences found in the baseline results between the two treatment arms.See Table 1 for demographic characteristics.

Treatment effects (informant-report)
A statistically significant change over time was found in the LCQ scores for both the standard and intensive GIST (Table 2).There was no statistically significant group-time interaction or group difference between the groups.The calculated effect size was very small, indicating a very small difference between the standard and intensive GIST results.A sensitivity analysis excluding possible outliers confirmed these results.The SCSQ-A and BRIEF-A showed a statistically significant improvement over time for both the standard and intensive GIST, and there was no statistically significant group-time interaction or group difference found between the groups.
The GAS results showed that the majority of the family members/friends (standard GIST: 95.0-100%; intensive GIST: 88.2-100%) reported improvements in all three social communication goals immediately post-treatment.The results were maintained at the 3-and 6-month follow-ups, with no statistically significant group differences between the treatments found on the chi-square tests.A statistically significant change was found between pre-and posttreatment, and between pretreatment and 6-month follow-up for both the standard and intensive GIST (Table 3).In the intensive GIST arm, the family members/friends still reported a statistically significant positive change in one of the goals at the 3-and 6-month follow-ups.

Qualitative results
Three overall themes were identified based on the categories found in the interview data.Two of the themes described the family members/friends' perception of social communication skills before and after standard and intensive GIST.The last theme described the family members/friends' perception of the treatments and their role as support-persons (see Table 4).
In the first theme, social communication skills before treatment, the following categories emerged; premorbid communication, consequences of ABI, and social environment.Most of the family members/friends described the premorbid communication skills of the persons with SCDs as normal, good, or very good.However, one friend reported that she did not know the person with SCDs before the injury, and two family members/friends expressed that the persons' communication skills had changed slowly over time (e.g., tumor).Addressing the consequences of SCDs and ABI, Helen (standard GIST) said, 'He had quite large problems with taking in what was said and taking turns and all that.At the time, it was difficult to communicate with him'.Norah (standard GIST) said, 'She struggled with interpreting others' body language and such (. ..) and was very uncomfortable in social settings'.
Within the second theme social communication skills after treatment, the following categories emerged: change after treatment, goal achievement, increased awareness, SCDs, and change in relationship.The majority of family members/ friends from the standard GIST group (5/6) and the intensive GIST group (3/3) reported a positive change in the social communication skills of persons with SCDs after treatment.Anne (standard GIST) did not report any change after Notes: The results were analyzed with the intention to treat principle including all close family member/friends who participated in the standard and intensive GIST.Change shows positive (+), negative (-) and tied ranks between each test point.GAS = Goal Attainment Scale; S-GIST standard group interactive structured treatment; I-GIST = intensive group interactive structured treatment.Median = Percentiles 50th, median differences between the two measure time points.treatment and explained this as follows: 'No, they (the social communication skills) were very good before the treatment.'Mark (intensive GIST), on the other hand, said 'Yes, to the better.'When the interviewer asked, 'What do you think is the cause of this change?'He said, 'I saw a very big change from when you (the researcher) just started the project and she was in, until she was finished.That was when most of the changes came.And the improvements.'Six out of the nine family members/friends expressed an increase in awareness after the treatments (2/3 intensive GIST; 4/6 standard GIST).Some reported increased awareness related to individual goals specifically, which made it easier to give feedback on social behavior.Helen expressed that 'I don't think he consciously thinks about the goals, but that he thinks more like; let them talk, ask how they are doing and what they have been up to lately,' which addressed measures that were practiced achieving a certain goal.Norah (standard GIST) said 'She has become very aware of them (the goals), but it (her social communication skills) hasn't improved that much, but the fact that she is aware is a step in the right direction anyway.'Some of the family members/friends reported a closer relationship with the person with SCDs after treatment; however, George (standard GIST) expressed that being a support person in the treatment was 'slightly more demanding than expected in terms of relationships.' Regarding the third theme, support persons' experiences from the treatments, three subcategories evolved: support persons' role, personal needs and future directives.All the family members/friends emphasized that their participation in the treatments was positive overall.One family member (standard GIST) expressed that it was not always easy to motivate himself to initiate work on home assignments, and that some of the topics were challenging considering previous experiences.On the other hand, Dan (standard GIST) expressed, 'I think it is just generally incredibly important for me to support and help my partner.'None of the family members/friends reported any personal needs for the future (e.g., next-of-kin seminars, information to relatives about SCDs).However, nevertheless, Stuart (intensive GIST) expressed that he was tired and felt quite alone as a care provider.Some of the family members/friends gave feedback about the treatments for further development and suggested more intensive treatment (standard GIST), regular follow-up after treatment to work on the social communication skill goals, and a more detailed summary from the group discussions in the workbook to ease the home-assignment discussions.Daniel (standard GIST) also highlighted that the informant questionnaires were time-consuming and extensive to fill out due to the number of questions and similar wording.
When integrating the qualitative and quantitative data, we found that the family members/friends reported a positive change in the social communication skills of the persons with SCDs following standard and intensive GIST.The positive change was statistically significant over time for the measures for social communication (LCQ; SCSQ-A) and for executive function (BRIEF-A) and expressed by most family members/friends during the interviews.

Discussion
In the present study, we examined whether and how family members/friends perceived changes in the social communication skills of persons with SCDs following standard or intensive GIST and compared improvements between the two treatments at the 6-month follow-up.By triangulating the quantitative and qualitative results, we found converging results suggesting that the family members/friends perceived an improvement in social communication skills after both treatments at the 6-month follow-up.Our quantitative data were measured with the use of standardized questionnaires for social communication (LCQ; SCSQ-A) and a predefined scale assessing goal achievement (GAS).The use of generic questionnaires in informant-report assessments of persons with SCDs has shown varying results in previous studies (23).Although the LCQ has shown high psychometric quality and sensitivity in other studies (28,47), one criticism concerned the lack of personal aspects included (14).A recent review identified the SCSQ-A as the only measure for social communication used in the included studies that actually asked about the persons' communication preferences and demands (14).However, a drawback with the SCSQ-A is the lack of norms.The GAS has also been suggested to be a more sensitive measure for identifying changes in SCDs than the LCQ (43).Thus, by using the LCQ, SCSQ-A, and GAS in our study, we were able to utilize the strengths and limit the weaknesses of the measures that contributed to strengthening our quantitative results.
In addition, by including the interview data, the family members/friends in our study were able to elaborate with examples on how they perceived the communication skills of the persons with SCDs, which is considered an important supplement to the quantitative data and gave us a better understanding of whether and how the communication skills changed (14).Exceptionally, one of the family members/friends reported during the interview that she did not experience a change in social communication skills after treatment due to already good communication skills before the treatment started, even though all participants with SCDs included in this study fulfilled the inclusion criteria of presenting SCDs (29) (Supplementary file 1).This statement may illustrate one of the challenges with differentiating and characterizing normal communication and SCDs in some situations and cases.

Self-awareness and goal attainment
Reduced self-awareness is a fairly common symptom of SCDs, often associated with executive dysfunction (5,7).The use of individual goal setting combined with support from significant others in treatments has previously been used as a method for increasing awareness for persons after ABI (20,22,48).
Awareness related to the strengths and challenges of persons with SCDs is considered one of the core elements of the GIST-program (see Supplementary file 2).It is facilitated by learning new social competence skills, establishing individual goals for social communication, and working on achieving these goals in addition to receiving feedback from therapists, group members, and family members/friends (26).
In our study, the quantitative GAS scores suggest that most of the family members/friends from both the standard and intensive GIST arms perceived achievement in all three social communication skill goals following treatment, with the results maintained at the 3-and 6-month follow-ups.Importantly, during the interviews, the family members/ friends reported a positive change in the persons with SCDs' self-awareness related to their communication skills after standard and intensive GIST and based on measures to improve social communication.One might expect that the increased self-awareness may influence persons with SCDs to report more difficulties in social communication following the treatments, i.e., to be more self-critical.However, this was not the case, as the self-reports (LCQ; SCSQ-A; BRIEF-A) in our previous study (29) describe similar patterns of improvement for persons with SCD compared to the informant reports made by family members/friends and thereby support the assumption that the informant reports in our study were valid (7).The reason for this may be that the persons with SCDs experienced increased self-awareness, but at the same time also increased social communication skills related to the GIST's focus on skill mastery and building on the person's strengths in communication (29).
However, integrating the GAS findings with qualitative data was challenging.First, the GAS used in this study was not directed specifically toward self-awareness; however, the family members/friends' results were in line with the self-reported GAS findings in our previous study (29).Second, family members/friends were not asked to elaborate on goal achievement specifically during the interview.For example, one family member/friend (Norah) expressed that she perceived a change in the awareness of SCDs but not in the social communication skills (the goal) per se.Looking at the quantitative GAS results alone, we found that overall, goal attainment was reported after treatment and at follow-up.These results were also supported by the results from the questionnaires (LCQ; SCSQ-A; BRIEF-A) and the overall qualitative results.One possible explanation is that Norah's quote is not representative of the remaining family members/friends in the sample, as the statement was made by only one of the 9 family members/friends interviewed.However, since the participants were not asked directly to elaborate on goal attainment in the context of awareness, it is difficult to integrate this finding.Hence, adding questions about goal attainment in the interviews would have strengthened and eased the integration of our results further.However, in contrast to Norah's quote, she reported goal achievement (on the GAS) for all three goals at the 6-month follow-up.The reason for these contradictory reports between the GAS results and the interview remains unknown.Nevertheless, the differences add an important layer to the interpretation of these findings and to the complexity of assessing goal achievement.Although the GAS has shown strong sensitivity, validity, and reliability in previous studies (42,43), our results indicate that individual interpretation and variation can still influence the results.

The role of family members/friends in treatment and in life
The quantitative generalized linear mixed model analysis indicated that the type of relationship did not affect the outcome results (Table 2).Despite the varying relationships, the majority of the family members/friends in the quantitative sample reported that they knew the person with SCDs very well at baseline.Only a few family members/friends reported that they did not know the person with SCDs that well (pretty good (n = 2) or to a small degree (n = 2)) (Table 1).In the qualitative sample, all the family members/friends reported that being a support person had been a positive experience for them, and some (n = 3) expressed that the treatment led to an even closer relationship to the person with SCDs than before treatment.Triangulation of these results indicated that, despite the close relationships reported at baseline, being a support person during the treatment process may have led to an even closer relationship between the family members/friends and the person with SCDs.Examples that were highlighted included that participation allowed them to gain a better understanding of the injury, SCDs and the importance of feedback and that the home assignments made them talk about things they would not talk about otherwise.Similar results indicating increased confidence and an increased ability to support and facilitate persons with SCDs in conversations and social situations were found for the family members/friends included in other treatments for SCDs (e.g., communication partner training) (24,49).
Of note, family members/friends' role in GIST is more indirect and mainly related to supporting, giving feedback, and working on home assignments and therefore differs from their role in direct communication partner training.However, similar results suggest a need for further investigation of the role of family members/friends in SCD treatment.In this study, the family members/friends expressed their own experiences of being part of the treatments.Some of the family members/friends communicated that being part of the treatment was educational and that meeting and sharing experiences with the persons with SCDs and other peers during treatment was positive and important.Similar results were found in a previous trial (25).In addition, as seen in Table 3, the family members/friends in the intensive GIST group reported a significant positive change in one of the three goals (on the GAS) between the posttreatment and 3-and 6-month follow-ups.This indicates that despite maintenance of improvements at posttest and follow-ups, the family members/friends still experienced a positive change after treatment ended.A reason for this can be the need for more time after treatment to assess the goal achievement of the persons with SCDs, as the treatment was delivered in an inpatient setting with limited time for practice in the home environment.In our study, only a small sample reported that they did not know the person with SCDs that well before the treatment; however, in light of the increased risk of social isolation associated with SCDs (4), further investigation of the importance of involving support-persons in treatment who are in close relationships seems feasible.Future studies should therefore investigate the importance of family members/friends' role, relationships, and the degree of necessary involvement of family and friends in SCD treatment.

Future research and clinical implications
Our findings confirm the results from our previous paper investigating the efficacy of standard and intensive GIST from the perspective of persons with SCDs (29).Even though our sample size was relatively small, the use of a mixed method approach allowed us to gain novel insights from our data.However, our study should be repeated with larger samples for the different arms.
Our results indicate similar outcomes between standard and intensive GIST which strengthens the possibility of offering GIST in various formats, depending on available resources.At the same time, it raises new research questions concerning the effect and impact of the different treatment components of GIST (e.g., practice in home environments, homework, and involvement of family/friends).Furthermore, some of the family members/friends provided feedback for further development of the treatments, and suggested more intensive treatment for the standard GIST, regular follow-up meetings for the persons with SCDs after the main course and extra notes from the sessions in the workbook to ease the family members/ friends´ role during the home assignments.This feedback and suggestions all seem feasible based on the previous findings discussed and should be explored further in future research.
In addition, a further investigation of the intensive GIST protocol is warranted for persons with SCD where inpatient treatment is a requirement, for example in complex ABI cases or in the subacute phase, or as an alternative option for people who live isolated lives.Although the less resource-and costintensive intervention may be adequate for individuals with SCDs in the chronic phase to improve, both intensive and standard treatments may be provided in different formats (e.g., outpatient, inpatient, telehealth).Future effect studies should therefore also include a cost-effectiveness perspective at both the individual and health care system level.The assessment tools warrant also further investigation, where similar wording in the different questionnaires was expressed as difficult.This feedback addresses an important issue regarding the existing drawbacks of SCD assessment (14,15) and reinforces the need for further development of distinguished and adequate assessment measures for SCDs in the future.

Study limitations
A major limitation in the quantitative results was that the sample did not reach the a priori calculated sample size, reducing the statistical power.In the qualitative results, the intensive GIST sample was smaller than the standard GIST sample, which led to fewer examples and elaborations from intensive GIST compared to standard GIST.Another limitation when using family members'/friends' reports is the assumption that the information gathered is valid.The fact that our findings confirmed the self-report data in our previous paper strengthens this assumption.In retrospect, we also recognize that additional questions regarding goal attainment in the interviews could have strengthened the results further and eased the data integration process.

Conclusion
The integrated findings of this study suggest that family members/friends from both interventions perceived improvement in the person with SCDs' social communication skills after treatment, with results maintained at the 6-month follow-up.The interviews provided rich descriptions of perceived change that add an important layer to the complexity of assessing social communication skills; that would not have been seen by analyzing only quantitative data.In addition, investigating the treatment outcome perspectives of family members/friends reveals valuable insight and knowledge concerning their role and support for the efficacy of treatment for persons with SCDs following ABI.

Figure 1 .
Figure 1.Overview of the parallel mixed methods design and data collection.

Table 1 .
Demographics characteristics of the informants and baseline data from questionnaires (n=49).Latrobe Communication Questionnaire; SCSQ-A = Social Communication Skills Questionnaire-Adapted; BRIEF= Behavior Rating Inventory for Executive Functions.M = mean; SD = standard deviation; standard GIST = standard group interactive structured treatment; WL= wait list control; intensive GIST = intensive group interactive structured treatment.The scores for the LCQ are presented as reversed raw scores and SCSQ-A and BRIEF-A as raw scores.For the LCQ lower total scores indicate fewer reported social communication difficulties (SCDs); for the SCSQ-A, higher total score indicate fewer reported SCDs; and for the BRIEF-A, higher total scores indicate more executive difficulties.

Table 2 .
Family members/friends' experience of change after standard and intensive GIST post-treatment and at 3-and 6-month follow-ups: estimated marginal means from generalized linear mixed models.

Table 3 .
Goal attainment scale results of family member/friends.

Table 4 .
Coding scheme.Overview and description of themes, categories and example quotes from the qualitative results.
So, it has made it much easier to bring these things up with him, you know.Because now we have a reason to talk about it (Helen, standard GIST) Personal needs for the future No, I don't really have that.Now, everything is going so well, so I actually feel in a way that it's okay (Mark, intensive GIST) Future directives There should have been a little more of what you talked about at the various gatherings (. ..) because she did not always remember what you talked about today, because there were so many impressions and things that happened at the same time during the course.(George, standard GIST)