Introduction

Stroke is a major cerebrovascular disease caused by the hemorrhage or infarction of a blood vessel in the brain, leading to a decline in motor, cognitive, sensory, and emotional abilities. This functional decline makes it challenging for individuals to perform daily activities [1]. Long-term functional impairment in stroke patients leads to life-altering experiences that necessitate constant care, impose financial burdens from rehabilitation and medical expenses, and result in role changes that limit their independence and autonomy [2]. The complex disabilities arising from stroke also limit an individual’s ability to engage in various activities and tasks [3]. In addition to these challenges, stroke survivors face psychosocial issues, including a decreased quality of life due to impaired physical function and altered appearance [4]. They suffer from negative social relationships due to their changed circumstances, economic losses from sequelae, and depression stemming from feelings of psychological helplessness and shame about their altered selves [5]. Anxiety is another prevalent stress factor among stroke patients, exacerbated by concerns over physical imperfections, the burden of hospitalization, and the difficulties associated with returning to work [6]. This anxiety persists for years after the stroke onset, adversely affecting social functioning, disease prognosis, and activities of daily living [7–9].

Rehabilitation motivation significantly impacts the recovery rate from post-stroke sequelae [10,11], and it is crucial to motivate hospitalized stroke patients to engage in rehabilitation to enhance outcomes [12]. This motivation encompasses the psychological desire to adapt quickly to a changed lifestyle and includes the desire, trust, and courage to undergo rehabilitation [13,14]. Active engagement in treatment is essential for successful rehabilitation, necessitating strong rehabilitation motivation [15]. Self-efficacy refers to an individual’s confidence in their ability to successfully perform specific actions [16] and encompasses the belief in one’s capacity to organize and execute the steps required to achieve desired outcomes [17,18]. Higher self-efficacy levels can boost rehabilitation motivation, enhancing the performance of purposeful activities and participation in rehabilitation [19]. Therefore, it is critical to focus on both self-efficacy and rehabilitation motivation to ensure active involvement in rehabilitation, and implementing effective clinical interventions to improve these factors is crucial [20–22]. Currently, rehabilitation treatments for stroke patients typically include occupational, physical, cognitive, swallowing, and speech therapies. Although these therapies improve physical function, they fall short in addressing psychosocial issues and do not constitute a comprehensive approach to rehabilitation that ultimately enhances patients’ quality of life [23]. Cognitive behavioral therapy (CBT) is a widely used intervention proven effective for managing psychosocial issues, particularly depression and anxiety. The fundamental premise of CBT is that symptoms like depression can be alleviated through cognitive restructuring, which involves identifying, challenging, and correcting faulty core beliefs and negative automatic thoughts about oneself that exacerbate negative feelings [24,25]. In addition to cognitive restructuring, behavioral modification plays a key role in CBT. Techniques such as behavioral activation, social skills training, assertiveness training, and role-playing are commonly employed. Behavioral activation specifically addresses the tendency of depressed individuals to avoid goal-oriented or enjoyable activities and instead engage in behaviors that perpetuate a depressed mood. This method involves a systematic analysis of behavioral patterns within specific contexts and promotes activities that provide pleasure and fulfillment [26].

Occupational therapists play a key role in mental health rehabilitation. In both the United Kingdom and the United States, they receive training in CBT and apply it in practice. Although occupational therapists in various countries are using CBT for a range of conditions, including insomnia and traumatic brain injury [27,28], its application in stroke patients is notably rare. Furthermore, no studies have been conducted that combine qualitative analysis of participants’ experiences with quantitative analysis. Therefore, this study aimed to explore the effects of a CBT program developed by the author on stroke patients by conducting a quantitative analysis to compare the assessment scores of stroke patients before and after their participation in the program, as well as a qualitative analysis to examine their experiences during the program.

Materials and Methods

Participants

The study was conducted from June to September 2023 and involved 20 stroke patients who were selected from those receiving inpatient treatment at C General Hospital, I Rehabilitation Hospital, and O General Hospital in Cheongju City. These patients met the following inclusion criteria: (1) a stroke diagnosis confirmed by a physician; (2) a Korean Mini-Mental Examination-2 (K-MMSE-2) score of 24 or higher; (3) the ability to write, read, and communicate without impairment; and (4) no presence of aphasia. The exclusion criteria included: (1) recent participation in a drug trial; (2) severe vision impairments; and (3) current use of psychiatric medications.

Protocol

This study was designed as a single-blind, randomized controlled trial (RCT). A total of 20 participants who met the inclusion criteria were enrolled. An occupational therapist, who was not involved in the study, assigned 10 subjects to each of the experimental and control groups using block randomization and a table of random numbers. The assignment results were communicated to the researcher by phone, and the group assignment process was concealed. The experimental group underwent 30 minutes of CBT followed by 30 minutes of general occupational therapy, totaling 60 minutes per session, 5 times a week, for 4 weeks. Similarly, the control group participated in 30 minutes of meditation relaxation followed by 30 minutes of general occupational therapy, also totaling 60 minutes per session, 5 times a week, for 4 weeks. An in-depth interview was conducted with the experimental group at the end of the intervention. To maintain single-blindness, all participants were unaware of their group assignments. The sessions were conducted in separate rooms, and the purpose of the experiment was not disclosed. The study was carried out by 3 occupational therapists, each with at least 5 years of experience, and included pre-assessment, intervention, post-assessment, and in-depth interviews with the experimental group.

The author trained 2 therapists before the study began, instructing them on the use of Socratic questioning throughout the program, the application of the negative automatic thought checklist after the sixth session, and the implementation of behavioral techniques in each session. Throughout the program, they maintained regular communication through Zoom video chats, phone calls, and face-to-face meetings to discuss progress and provide feedback. In the control group experiments, participants were blinded to their group assignment and were asked to work individually in separate rooms. Therapists who provided interventions to both the experimental and control groups received the same training and participated in identical meetings to ensure consistent treatment fidelity across both groups. The procedure is visually depicted below (Figure 1).

Measurements

Cognition

The K-MMSE-2 was utilized as a screening tool for cognitive impairment. This scale comprises 11 items across 7 domains: memory registration, time perception, spatial perception, memory recall, attention and computation, language, and drawing. The total score is derived by adding the scores from each item, ranging from a minimum of 0 to a maximum of 30 points. Scores of 17 or below indicate moderate cognitive impairment, scores between 18 and 23 suggest mild cognitive impairment, and scores of 24 or higher denote normal cognitive function. According to the study by Kang et al. [29], the test-retest reliability was 0.69, and the interrater reliability was 0.99.

Depression

The Korean Beck Depression Inventory-2 (K-BDI-2) was utilized to evaluate depression levels. This 21-item questionnaire encompasses behavioral, emotional, cognitive, and physiological symptoms of depression. Each item is rated on a scale from 0 to 3 points, with the scores then aggregated to yield a total score. The total score can range from 0 to 63 points, where a higher score reflects a greater level of depression. Specifically, scores from 0 to 9 suggest no depression, scores from 10 to 15 indicate mild depression, scores from 16 to 23 suggest moderate depression, and scores of 24 or above indicate severe depression. The reliability of the scale was reported as 0.80 [30].

Anxiety

The State Trait Anxiety Inventory-Korean YZ (STAI-KYZ) was utilized to evaluate changes in anxiety levels. Anxiety psychology is divided into state anxiety and trait anxiety. The inventory comprises 20 items, each rated on a 4-point scale, yielding a total score range of 20 to 80 points. A higher score indicates a greater level of anxiety. State anxiety measures the emotional state of a participant at a specific moment, characterized by subjective feelings of agitation, tension, worry, and concern. These feelings are typically due to the activation or arousal of the autonomic nervous system. Conversely, trait anxiety evaluates the general emotional disposition of the participant, aiding in distinguishing between neuroticism and depression in patients. The reliability of the scale was reported to be 0.88 [31].

Self-efficacy

A self-efficacy scale was utilized to evaluate changes in self-efficacy. This scale comprises 10 items, each rated on a Likert scale that spans from 1 point, indicating “not confident at all,” to 10 points, signifying “very confident.” These ratings assess how confident stroke patients feel about performing common activities of daily living. The scale includes 1 item each for eating, personal hygiene, and dressing; 2 items each for toileting and walking; and 3 items for repositioning. The total score can range from 10 to 100 points, with higher scores reflecting greater self-efficacy. According to the study by Kim and Kim [32], the reliability of the scale was 0.97.

Rehabilitation motivation

The stroke rehabilitation motivation scale was utilized to evaluate rehabilitation motivation. This multidimensional scale comprises 27 items, each scored on a 4-point scale. It categorizes motivation into 5 types according to the level of self-determination: task-oriented motivation (8 items), change-oriented motivation (7 items), obligatory motivation (4 items), external motivation (4 items), and amotivation (4 items). Higher scores on this scale indicate greater motivation. In the study conducted by Kim et al. [33], the scale demonstrated a reliability of 0.86.

In-depth interview questionnaire

In-depth interviews were conducted for the qualitative analysis of this study. The researcher established rapport with participants during treatment sessions, forming close relationships and explaining the study’s purpose and the significance of their participation. Consent was obtained from participants prior to the interviews, which were recorded and lasted approximately 50 minutes to 1 hour each. The in-depth questionnaire was developed based on a survey and literature review addressing common complaints among stroke patients. The interview questions were organized around key themes the author aimed to explore. The main questionnaire included semi-structured, open-ended items such as: “How has your experience in the program influenced your relationships with other patients?”; “How has your mood (anxiety, self-efficacy, reactivity) changed since joining the program?”; “How have your thoughts shifted in response to negative situations since your participation?”; “Can you describe your experience with breathing exercises in the program?”; and “How do you think your experience in the program will impact your life after discharge?”

CBT Program Develop Process

A semi-open questionnaire was developed to draft a CBT program. This questionnaire was designed to gather expert opinions by presenting components, related topics, and descriptive questions that encouraged open-ended responses. Ten experts, each with over 3 years of clinical and educational experience in mental health, were selected to provide their insights. The first Delphi survey was conducted to categorize responses by domain, extract relevant items, and classify them based on the feedback obtained through the semi-open questionnaire. Following this, the second Delphi survey was carried out to develop a questionnaire informed by the results of the first survey. A 4-point Likert scale was used to assess the appropriateness of each item for inclusion in the CBT program. The data from the second Delphi survey were then organized to calculate the mean, standard deviation, content validity ratio (CVR), item-level content validity index (I-CVI), and the degrees of stability, consensus, and convergence for each item. In the third Delphi survey, feedback was solicited only for items where there was a lack of consensus among the experts, as indicated by the results of the second survey. The collected data were analyzed to calculate the mean, standard deviation, CVR, I-CVI, and the degrees of stability, consensus, and convergence for all items. The final program was established based on the outcomes of the third Delphi survey.

Intervention

The CBT program implemented for the experimental group in this study included cognitive restructuring activities aimed at correcting distorted negative automatic thoughts and beliefs throughout the participants’ involvement. It also featured self-administered worksheet activities based on behavioral techniques to foster emotional and behavioral changes, training in behavioral techniques, and interactive feedback and dialogue with the therapist. The program was structured into 3 phases: Sessions 1 to 3 constituted the introduction phase, focusing on general education about stroke and CBT principles; sessions 4 to 17 formed the development phase, emphasizing cognitive restructuring and behavioral interventions; and sessions 18 to 20 marked the termination phase, during which the skills acquired were reviewed and solidified through the completion of a termination log (Table 1). The control group participated in a meditation relaxation program, specifically the Korean Mindfulness Based Stress Reduction (K-MBSR) program, which was adapted and translated by Bae and Chang [34]. This program, designed by the author to suit an appropriate level of difficulty, comprises 4 components: breathing meditation, body scan, seated meditation, and walking meditation (Table 2).

Statistical Analysis

All statistical analyses for the quantitative data in this study were performed using IBM SPSS ver. 27.0 (IBM Corp.). The normality of the study subjects was assessed using the Shapiro-Wilk test. Due to the non-normal distribution of data, non-parametric methods were employed. Chi-square and descriptive statistics were utilized to analyze the general characteristics of the participants. The Mann-Whitney U test was conducted to ensure functional homogeneity prior to the intervention. Within each group, the Wilcoxon signed rank test was used to assess pre-post differences, while the Mann-Whitney U test compared differences between the 2 groups. The level of statistical significance was set at p<0.05. For the qualitative data, in-depth interviews were analyzed using NVivo (Lumivero), a qualitative analysis tool. The analysis was conducted in 4 steps: import data, set up a coding table, coding, and data analysis. During the import data step, files containing the transcripts of the in-depth interviews were imported. In the set up a coding table step, categories were established. The coding step involved creating nodes, coding textual materials sentence by sentence, and assigning them to the appropriate categories. Finally, in the data analysis step, a list of frequently used words and the frequency of each word were obtained.

Ethics Statement

The study protocol received approval from the Institutional Review Board (IRB) of the Science Research Ethics Committee at Cheongju University (IRB No: 1041107-202304-HR-078-01). The IRB also confirmed that informed consent was obtained.

Results

Quantitative Analysis Results

Demographics and baseline characteristics

The general characteristics of the participants are shown in Table 3. In terms of gender distribution, the experimental group included 6 men (60.0%) and 4 women (40.0%), whereas the control group comprised 4 men (40.0%) and 6 women (60.0%). The average age was 62.90±10.14 years in the experimental group and 60.10±8.18 years in the control group. Regarding the type of onset, the experimental group had 7 participants with infarction (70%) and 3 with hemorrhage (30%), while the control group had 6 with infarction (60.0%) and 4 with hemorrhage (40.0%). The mean duration of onset was 4.30±1.05 months in the experimental group and 4.40±1.07 months in the control group. There were no significant differences between the 2 groups in the initial assessment scores, which included gender, age, type of disease, paralyzed side, duration of disease, and K-MMSE-2 score (p>0.05).

Intervention outcomes

Table 4 shows the pre- and post-intervention results for depression, anxiety, specific self-efficacy, and rehabilitation motivation. In terms of depression and anxiety, the experimental group exhibited statistically significant improvements in depression, state anxiety, and trait anxiety after the intervention compared to before (p<0.01). The control group demonstrated significant reductions in state anxiety and trait anxiety (p<0.05), but no statistically significant changes were observed in depression scores (p>0.05). Significant between-group differences were noted in the changes in both depression and anxiety (p<0.01).

Regarding specific self-efficacy, the experimental group exhibited a statistically significant change post-intervention compared to pre-intervention (p<0.01). In contrast, the control group also demonstrated an improvement in scores post-intervention compared to pre-intervention, though this change was not statistically significant (p>0.05). Although the experimental group achieved greater score gains than the control group, the difference in changes between the 2 groups was not statistically significant (p>0.05).

For rehabilitation motivation, post-intervention scores in the experimental group showed a statistically significant improvement (p<0.05), whereas the control group did not exhibit a significant change (p>0.05). Although the experimental group demonstrated greater gains in scores compared to the control group, the difference in changes between the 2 groups was not statistically significant (p>0.05).

Qualitative Analysis Results; Experience Participating in the CBT Program

A qualitative analysis was conducted of the experiences of 10 participants in the experimental group who took part in the CBT program. This analysis identified 45 meaning units, 13 subcategories, and 4 core themes. The core themes were identified as psychological stability, physical symptom relief, altered daily routines, and challenges and hopes for change. The key findings from the study are summarized in the participant responses attached (Table 5). Additionally, NVivo was utilized to examine the 50 most frequently used words in the participants’ interviews. The analysis revealed that words such as “positive,” “thinking,” “relaxation,” “breathing,” “rehabilitation,” and “better” were commonly used (Figure 2).

Psychological stability

Alleviating depression

Most participants experienced depression following their stroke, which was a significant obstacle their emotional regulation.

“I would burst into tears talking about nothing. I would burst into tears even talking about something good. I couldn’t control my emotions, and I was very depressed. But I got better when I realized that I had to be realistic about my condition and keep doing things that I liked.” (Participant 2)

“My depression was so severe that I kept crying whenever I spoke. But when I practiced writing down my negative thoughts and feelings every day, I was really surprised to realize, ‘Oh, I have so many bad thoughts during the day.’ I practiced thinking positively a lot, and it really helped me.” (Participant 7)

Reducing anxiety

The participants expressed anxiety about their uncertain futures, potential for physical recovery, and negative prognoses. After engaging in the program, they noted a decrease in anxiety, which they attributed to recognizing cognitive errors and concentrating on their achievable actions.

“Without a caregiver by my side, I was always anxious and constantly looking for one, and I couldn’t focus on my treatment. I felt like I would fall if I was alone for even a moment. But now I know that the scary thoughts are not actually true, which has reduced my anxiety.” (Participant 4)

“I think I was anxious and worried about every little thing because bad things kept happening to me. Whenever I would get on and off my bike, or get up from a chair, my heart would race wondering if I was going to fall again. Once I realized that I was freaking out about things that hadn’t happened, and I tried to fix that, I felt a lot better.” (Participant 9)

Improving self-esteem

Many participants experienced low self-esteem and self-consciousness due to their altered physical appearance and reduced ability to perform daily activities. After participating in the program, they acquired skills to manage stress, recognize their blessings, concentrate on their strengths, and enhance their self-esteem.

“I’ve learned to love myself by giving myself compliments and looking for the things I’m good at. I was good at more things than I thought. I was too busy hating myself.” (Participant 4)

“When I started looking for things I’m grateful for, I realized I’m pretty good at a lot of things. In some ways, compared to the general population, I seem to have a severe disorder because I look a little unnatural, but compared to other patients, I am in good shape. I think it boosted my self-esteem a lot.” (Participant 10)

Accepting the current circumstances

Many participants found it challenging to accept the sudden changes in their appearance and were stressed by the decline in physical function and hospitalization. They reported that the program helped them release negative thoughts and accept their current circumstances.

“I used to have a lot of bad thoughts when I saw a code blue announcement, thinking, ‘I would end up like that.’ Now I do not feel that way because I think of myself as someone who will get better with a few months of rehabilitation.” (Participant 2)

“I was so embarrassed to wear an L-tube that even when my best friends came to visit, I turned them away, insisting that I would not come down. I didn’t want to look ugly to others. I felt so humiliated and ashamed. Now I try not to think about things that make me miserable, thinking, ‘Oh well, I’m sick now!’ This is how I cope with it.” (Participant 4)

Physical symptom relief

Reducing tension and relaxing the body

Many participants reported body tension and stiffness, which they attributed to repeated rehabilitation treatments and decreased muscle strength. By consistently practicing behavioral activation methods, including stretching, progressive muscle relaxation, and body scan meditation, participants noted a significant reduction in tension and an increase in relaxation.

“I always felt tense and stiff except when the therapists were working on my limbs, but after meditating, I felt more relaxed. I feel much better.” (Participant 4)

“After a muscle relaxation workout, my body feels relaxed and tired. It feels a lot less tense after you keep tensing and releasing.” (Participant 10)

Relieving pain

The participants described experiencing back pain due to fear of falling, headaches due to stress and sensitivity, and shoulder pain due to poor upper extremity strength. After participating in the program, they achieved pain relief through methods such as stretching, progressive muscle relaxation, and body scan meditation.

“I was sensitive and stressed; my blood pressure would go up, and I would get headaches because my neck was always tense. After stretching and relaxing my muscles, I feel like I am unwinding. I do it every day in the hospital room.” (Participant 5)

“I feel much more comfortable listening to my own recordings with my own voice. When I’m doing this (body scan meditation), my shoulder feels a little less painful, but strangely, the soles of my feet and palms of my hands on the paralyzed side, which felt numb, feel a little more sensitive.” (Participant 9)

Improving sleep quality

Some participants reported fatigue linked to poor sleep quality, which included difficulties such as not achieving deep sleep due to stress, frequent awakenings, or prolonged time taken to fall asleep. By engaging in meditation and stretching exercises, they were able to clear their minds of unnecessary thoughts, relax their bodies, and increase their comfort in bed.

“Learning to stretch and meditate has helped me the most. I always do one of those exercises before I go to bed, which has really reduced my stiffness.” (Participant 1)

“My daughter has recorded it and I listen to it all the time. When I listen to this (body scan meditation), I fall asleep quickly and my senses come alive as I focus on each and every part of my body.” (Participant 7)

Different daily routines

Improving the ability to cope with stress

Participants experienced heightened self-consciousness, reduced motivation for rehabilitation, and frequent impulsive negative thoughts due to disruptions in their routine and the stress impacting their physical functioning. After participating in the program, they learned various self-management techniques to cope with stress, including adopting positive thought patterns and practicing breathing and meditation techniques, which they can incorporate into their daily lives.

“I used to be a little bit snarky and aggressive, but now I feel like I am not as swayed by what people say, and I try to think positively. I realized that I was too conscious of what people around me were saying and letting my emotions take over.” (Participant 1)

“There are still a lot of situations that are similar to before, but I’ve learned how to deal with them and I’m mostly okay now. I’m doing a good job, but when I write it down and go back over it, there’s nothing that I should be particularly stressed about.” (Participant 3)

Focus on things one can do

The participants expressed dissatisfaction with the pace of their recovery and harbored pessimistic beliefs about their ability to resume their former lifestyles. However, after engaging in the program, they reported a shift towards a more positive outlook, an appreciation for the small joys in life, and a focus on the possibilities within their current circumstances.

“By focusing on what I can do and being grateful, I can see my improvement, even if it’s just a slight difference. (Demonstrates) Last week I could only twitch my finger, and now I can make a full fist and stretch it out. Before, I used to be annoyed at how little things got better and how I could even make ramen by myself. Now I am grateful for these little things.” (Participant 3)

“It made me realize that some of the things I thought were the worst things might not be as bad as I thought. It’s not just like, ‘Oh, what am I going to do now?’ I try to think of productive things and ways to do things, and I try to find things that I can do myself, even the smallest things.” (Participant 3)

Improving real-world relationships

The participants, who had become less independent and required the assistance of a guardian or caregiver in their daily lives, began to criticize themselves, harbored negative thoughts, and struggled to express their thoughts and feelings accurately. The program taught them to think positively, assert themselves, and express their emotions appropriately, resulting in improved relationships with others.

“I felt so sorry for my daughter and husband, but I decided not to feel sorry for them from now on. My daughter says she doesn’t want to hear me say I’m sorry. So now I’m grateful and I say thank you.” (Participant 2)

“The assertiveness training was probably the most helpful for someone like me. I’m a little bit self-centered, so... I realized that it doesn’t sound rude to use phrases that start with “I” when I have a complaint or want something, instead of blaming others. I try to say it that way nowadays.” (Participant 9)

Challenges and hopes for change

Aiming for a positive and rational attitude

Most participants experienced negative automatic thoughts stemming from their uncertain future, sudden decline in physical function, and frustration. However, after participating in the program, they recognized the cognitive errors they were repeatedly making in their daily routines. They endeavored to eliminate these errors and replace them with positive thinking. The program also encouraged them to seek evidence that contradicted their negative thoughts and to adopt a more rational perspective.

“Before, I used to be annoyed by grandpa making noise in the hospital room and other caregivers asking me what happened to me at such a young age, but now I’m not so angry because I’ve learned to think positively and rationalize things a little bit.” (Participant 1)

“I found it helpful to identify the errors in my thinking and how to turn them into good thoughts. When I tried to think about it that way, there was no emotion I could not overcome. It is a mindset that I hope to pass on to my students when I am able to go back to school.” (Participant 7)

Active participation in rehabilitation

After participating in the program, participants who initially found the rehabilitation period stressful due to psychological depression and anxiety reported a greater acceptance of their current situation and a more positive mindset. They achieved psychological stability, set personal goals through weekly activity plans, and engaged more actively in their rehabilitation.

“By thinking, ‘I’m going to be better this month than I was last month, and I'm going to be better next month,’ I am more focused and work harder. I used to try to leave 5 minutes early because I didn’t want to be bothered, but now I joke that they should let me do it more.” (Participant 3)

“I am supposed to write my rehabilitation goals in my planner every day. It makes me work harder. I am proud of myself on days when my achievement and enjoyment scores are both high. I did not think about having fun, but when I was scoring myself, it made me want to have fun and work harder.” (Participant 4)

Expectations for future changes

The participants, who initially were self-critical, suffered from low self-esteem, and lacked hope for the future, experienced a shift in mindset after engaging in the program. They began to appreciate the small joys in life. Furthermore, they reported that setting personal goals post-discharge has given them something to look forward to, fostering a sense of growth and change.

“I cried a lot when I read something written by someone who had a stroke. Like me, this person was scared to go back home, but in the end, did it for the kids. My kids are old enough to know better, but they’re still kids to me. I’m determined to be a strong mom.” (Participant 4)

“I have a renewed enthusiasm for returning to work. I used to have a reputation in the hospital as someone who cried at the slightest thing, but now my depression has gotten a lot better and I’ve found things I’m good at that I can do with a little help. I set a goal to rehabilitate myself and go back to school.” (Participant 7)

Discussion

This study aimed to explore the effects of a CBT program for stroke patients, focusing on its impact on depression, anxiety, self-efficacy, and rehabilitation motivation, as well as the patients’ experiences of participating in the program.

When comparing changes in depression levels before and after the intervention, a significant decrease was observed only in the experimental group, with a notable difference in the extent of change between the 2 groups. Initially, many members of the experimental group experienced depression post-stroke and struggled with emotional regulation. However, after engaging in the program, they reported a more positive outlook and developed effective stress management strategies. Thomas et al. [35] conducted a study where 48 stroke patients were divided into 2 groups: one receiving a behavioral activation intervention and the other receiving usual care. The results indicated that the experimental group experienced a reduction in depression. Similarly, Peoples et al. [36] found that when CBT was administered to cancer patients, those in the experimental group who received CBT exhibited a more significant reduction in depression compared to the control group, which did not participate in CBT. These findings align with previous research confirming the efficacy of CBT in alleviating depression.

The anxiety scores in this study exhibited a significant decrease in both the experimental and control groups. However, the reduction was more pronounced in the experimental group, with a statistically significant difference in the degree of change between the 2 groups. The control group participated in a meditation relaxation program derived from the K-MBSR program.

These findings align with those reported by Seo et al. [37], who found that participants in a mindfulness meditation group experienced significant reductions in anxiety compared to their control counterparts. Similarly, You et al. [38] observed that middle-aged women engaging in mindfulness meditation showed significant decreases in state anxiety scores relative to a control group that did not participate in the meditation. Additionally, the CBT program implemented in this study incorporated various relaxation techniques, including progressive muscle relaxation, stretching, breathing, and meditation, as well as cognitive restructuring activities. These components likely contributed to the enhanced psychological stability and more substantial anxiety reduction observed in the experimental group compared to the control group.

The self-efficacy test only showed a significant difference in the experimental group. In a RCT conducted by Johansson et al. [39], patients with cardiovascular disease who participated in an Internet-based CBT program exhibited a significant increase in self-efficacy compared to a control group that received conventional care. Similarly, Hyun [40] reported notable improvements in self-efficacy among chronic schizophrenia patients in the experimental group who received group CBT, as opposed to those in the control group. These findings suggest that CBT is an effective intervention for enhancing self-efficacy, which is defined as the “belief in one’s ability to organize and execute the behaviors necessary to successfully manage a given situation or task.” This is in line with the observed significant improvements in specific self-efficacy scores in the experimental group of this study, relative to the control group.

The experimental group exhibited a statistically significant increase in rehabilitation motivation scores, whereas the control group also showed an increase, but it was not statistically significant. Numerous rehabilitation experts contend that boosting a patient’s motivation for rehabilitation is crucial for successful outcomes [41]. They also emphasize that high rehabilitation motivation is essential for minimizing functional impairment and maximizing residual capabilities [42]. Following a stroke, patients often experience various disabilities that can lead them to become psychologically withdrawn, lose confidence, and disengage from the rehabilitation process. This disengagement can result in a passive approach to rehabilitation and ultimately delay recovery. Song et al. [43] discovered that depression, stemming from physical deterioration and maladaptation, diminishes adherence to rehabilitation. Similarly, Neau et al. [44] reported that depression not only increases fatigue and feelings of inadequacy but also lowers rehabilitation motivation, thereby reducing functional capacity and complicating the return to work. These findings align with the results of this study, where participants reported increased feelings of accomplishment, reduced depression, and enhanced engagement in rehabilitation after participating in the program. Notably, there were significant improvements in rehabilitation motivation among members of the experimental group compared to those in the control group.

To explore the experiences of stroke patients participating in a CBT program, interviews were conducted with 10 participants from the experimental group of this study. The qualitative analysis of these interviews yielded 45 semantic units, 13 subcategories, and 4 core themes. These themes were identified as “psychological stability, physical symptom relief, altered daily routines, and challenges and hope for change.”

The participants experienced enhanced psychological stability, reduced depression and anxiety, and improved self-esteem. These benefits arose from identifying their cognitive errors, practicing the release of unnecessary thoughts, avoiding extremes, and recognizing their capabilities and strengths. In this study, patients were instructed to maintain a thought-reframing log to document their automatic thoughts and emotions during stressful situations. This process helped them pinpoint cognitive errors and discover rational alternatives. Dobson et al. [45] noted that CBT can initiate behavioral changes, which foster rational cognitive adjustments, subsequently leading to effective coping behaviors. Similarly, Franklin et al. [46] observed functional changes in neural circuits involved in emotion regulation, reward processing, and cognitive control related to depression. These changes were noted after participants engaged in a cognitive task, lending support to the findings of this study.

The participants reported physical issues including stiffness, shoulder pain, headaches, and insomnia. However, their involvement in the program led to a more relaxed body, reduced pain, and better sleep quality. Nguyen et al. [47] conducted a study on stroke patients and found that those in an experimental group participating in a CBT program experienced less fatigue and improved sleep quality compared to a control group that received standard rehabilitation. Similarly, Murphy et al. [48] applied CBT to patients with osteoarthritis, achieving reductions in pain, stiffness, and fatigue. In a RCT involving patients with diabetic peripheral neuropathic pain [49], a CBT intervention was linked to decreased neuropathic pain intensity and enhanced mental health scores, in contrast to a control group that received diabetes education. These findings suggest that CBT not only positively impacts emotional issues such as depression and anxiety but also improves physical symptoms and sleep quality through its behavioral techniques.

After participating in the program, participants reported an increase in their ability to communicate positively and effectively with their families, as well as a boost in their motivation for rehabilitation. The program also instilled in them future goals and altered expectations about potential changes in their lives. This improvement may be attributed to various program components such as assertive communication, planning weekly activities, practicing problem-solving skills, and creating coping card strategies. These elements were instrumental in helping participants replace negative thoughts with positive ones, devise reasonable solutions and coping strategies, achieve a sense of accomplishment, manage stress, and learn effective self-expression. Furthermore, many participants noted an improved ability to concentrate on their current capabilities. This shift is likely due to the cognitive restructuring activities included in the program, which addressed their pervasive negative thoughts about never being able to return to their previous lives. These activities taught them to think positively, appreciate the small joys in life, and maintain a focus on the present.

Participants were asked to repeatedly identify their cognitive errors, substitute them with positive thoughts, and gather evidence to challenge their negative beliefs. In-depth interviews indicated that participants experienced personal growth throughout the program, which enhanced their eagerness to return to work, strengthened their resolve to be better mothers, helped them recognize their competencies, and fostered hope and a plan for post-discharge change. This improvement may have stemmed from program activities that involved rating their negative emotions in challenging situations, as well as assessing their sense of accomplishment and enjoyment from their planned activities. As the sessions advanced, participants could visually observe their progress, evidenced by a decrease in their negative emotions scores and an increase in their scores for accomplishment and enjoyment.

There are several limitations to this study. First, the small sample size makes it difficult to generalize the findings to all hospitalized stroke patients. Second, participants with paralysis in their dominant hand may not have been able to describe their feelings in sufficient detail, as they could only complete the worksheet with assistance from family, caregivers, or therapists. Third, there has been no follow-up to verify the sustainability of the study’s results. To address these limitations, future research should increase the sample size, develop programs that utilize tablets or computer to allow participants to engage with just a simple touch, conduct follow-ups to ensure the program’s lasting effects, and create a detailed guidebook for therapists to facilitate professional intervention. Recent research trends in other countries have included telephone-based CBT, Internet-based CBT, and self-help programs. However, more research is needed in Korea using a broader approach. This would expand the scope of the study to not only include hospitalized stroke patients but also those receiving home-based care and patients with other conditions.

Conclusion

This study aimed to implement a CBT program developed by the author for stroke patients and to evaluate its effectiveness through both quantitative and qualitative analyses. The quantitative analysis demonstrated that CBT positively impacted depression, anxiety, self-efficacy, and rehabilitation motivation among stroke patients. Meanwhile, the qualitative analysis offered deeper insights into the participants’ subjective experiences and perceptions of the program, which were not captured by the quantitative data. The findings from the qualitative analysis revealed psychological stability and alleviation of physical symptoms, leading to changes in daily routines. The challenges faced by the participants instilled a sense of hope. Given the lack of systematic studies on CBT programs for stroke patients both nationally and internationally, this study suggests that CBT could be a valuable intervention within the field of occupational therapy.

HIGHLIGHTS

• This study conducted a quantitative analysis of the effects of a cognitive behavioral therapy (CBT) program administered to stroke patients and a qualitative analysis of the participation experience.

• The CBT program showed positive effects on stroke patients’ mental health, self-efficacy, and motivation for rehabilitation.

• The findings suggest that CBT may serve as a useful intervention method in the field of rehabilitation treatment.

Article information

Ethics Approval

This study was approved by the Institutional Review Board of Science Research Ethics Committee of Cheongju University (IRB No: 1041107-202304-HR-078-01) and performed in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained for publication of this study and accompanying images.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

None.

Availability of Data

The datasets are not publicly available but are available from the corresponding author upon reasonable request.

Authors’ Contributions

Conceptualization: all authors; Data curation: SEC; Formal analysis: all authors; Methodology: DKJ; Project administration: all authors; Resources: all authors; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Figure 1.

Flow chart of the study process.

K-MMSE-2, Korean Mini-Mental Examination-2; K-BDI-2, Korean Beck Depression Inventory-2; STAI-KYZ, State Trait Anxiety Inventory-Korean YZ.

Figure 2.

Frequent words that appeared in the interviews.

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