Stability of Psychological Well-being Following a Neurological Event and in the Face of a Global Pandemic

Abstract

This study examined the stability of psychological well-being in people who have experienced a neurological event resulting in focal brain damage. Evidence suggests that psychological well-being is largely stable in healthy adult populations. However, whether such stability exists in neurological patients with acquired brain lesions is an open question. Given the trait-like characteristics of psychological well-being, we hypothesized that psychological well-being would be stable in neurological patients who are in the chronic epoch of recovery (≥3 months after the neurological event). Eighty participants (women = 40; age: M = 56, standard deviation (SD) = 13) completed the Ryff Scales of Psychological Well-Being (PWBS) twice between 2016 and 2020 (Time 1 [T1] and Time 2 [T2]). The Ryff Scales measure various facets of well-being, including autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Approximately half of participants completed their T2 assessment during the COVID-19 pandemic, creating an opportunity to investigate the effects of the pandemic on the stability of psychological well-being in a neurological population that may be particularly vulnerable to reduced well-being in this context. Pearson correlations and within-sample t-tests were conducted to examine the stability of self-reported well-being over time. Test–retest correlations ranged from .71 to .87, and no significant differences in well-being emerged across the two time points. Significant correlations between T1 and T2 were also evident in the subsample of participants who completed their second assessment during the COVID-19 pandemic. These findings provide evidence that long-term psychological well-being is remarkably reliable and consistent over time in patients who have experienced a major neurological event, even when an unprecedented global event occurred between measurement epochs. Treatment implications of these findings are discussed.

Psychological well-being has been a topic of great intrigue in recent years, not only among the scientific community but also among the general public. Various definitions of well-being exist in the literature, and the term “well-being” is often used interchangeably with related constructs such as quality of life and life satisfaction. Broadly, well-being refers to optimal functioning or how people are doing in life (Diener et al., 2018; Ryan & Deci, 2001). Well-being can be understood in the context of many domains of life (e.g., health, interpersonal relations, and economics) and can be examined from both individual and societal perspectives. Given its vast applicability and inherent importance, it is perhaps unsurprising that scholars, scientists, and clinicians have attempted to operationalize and understand well-being for centuries. From a rehabilitation counseling perspective, it is argued that well-being should be one of the major goals of treatment (Chou et al., 2013; Hampton, 2004).

Defining Psychological Well-being

Contemporary investigations of well-being reflect a growing awareness that well-being is not simply the absence of mental or physical illness or disability but is rather a related but separable construct (Keyes, 2005; Ryan & Deci, 2001; Seligman & Csikszentmihalyi, 2014). Subjective well-being and psychological well-being are two common frameworks for investigating well-being from a psychological perspective. Subjective well-being is comprised of three components—positive affect, negative affect, and satisfaction with life—and captures both affective and cognitive aspects of the good and bad elements of life (Andrews & Withey, 1976; Diener et al., 1985; Disabato et al., 2016; Kahneman et al., 1999; Lucas et al., 1996; Ryan & Deci, 2001). Psychological well-being is a theory-driven formulation of well-being, integrating perspectives of positive psychological functioning postulated by Aristotle, Maslow (1968), Rogers (1961), Jung (1933), and Allport (1961). Psychological well-being is defined along six dimensions: autonomy, environmental mastery, personal growth, positive relations with other, purpose in life, and self-acceptance (Ryff, 1989). This six-factor model of psychological well-being is well-supported in the literature and arguably captures aspects of well-being beyond happiness, per se (Ryff & Keyes, 1995; Ryff & Singer, 2006). While subjective and psychological well-being stem from two distinct historical inquiries into the study of well-being, current models suggest that these constructs are highly correlated (Disabato et al., 2016; Keyes et al., 2002) and are both related to physical and mental health outcomes (for reviews see Diener & Seligman, 2004; Lyubomirsky et al., 2005; Ryan & Deci, 2001; Ryff, 2014; Ryff & Singer, 2013).

Psychological Well-being, Health, and COVID-19

The topic of psychological well-being is even more relevant in light of the COVID-19 global pandemic—in an era where health is far from guaranteed, knowing what it means to be psychologically well gains new importance. Meta-analyses have found that psychological morbidities and stress levels related to the pandemic are prevalent at rates upward of 40% (Krishnamoorthy et al., 2020), an effect which is exacerbated in at-risk populations (Luo et al., 2020). Despite this, the 9th annual World Happiness Report found—perhaps surprisingly—that happiness has been remarkably stable over the past years (Helliwell et al., 2021).

Research shows that high psychological well-being may act as a buffer during stressful times (DuPont et al., 2020). Not only is psychological well-being connected to emotional health, but it also plays an important role in physical health. Psychological well-being is associated with better physical health outcomes, particularly throughout the aging process (Kim et al., 2013). Older adults with higher purpose-in-life scores are less likely to have a stroke or myocardial infraction (Kim et al., 2013). They also demonstrate a decreased rate of physical decline (Saadeh et al., 2020). Furthermore, there is evidence that positive psychological well-being is correlated with higher survival rates among healthy and diseased populations (Alimujiang et al., 2019).

People who have experienced major medical events or are living with serious health conditions may be particularly vulnerable to reduced well-being. Extensive work has examined psychological outcomes in patients who have experienced a neurological event (e.g., stroke, tumor resection, and focal traumatic brain injury (traumatic brain injuries [TBI])). For example, research shows that during the acute phase of recovery following a neurological event psychological health often declines, with high instances of anxiety and depression (de Weerd et al., 2011). A meta-analysis investigating psychological well-being and personality traits following stroke found that patients high in neuroticism were particularly susceptible to diminished psychological well-being following stroke (Dwan & Ownsworth, 2019). In addition, higher rates of depression following stroke are associated with greater disability and increased mortality (Robinson & Jorge, 2016). Research also shows that people who have experienced TBI may be more likely to develop major depression or post-traumatic stress disorder (Stein et al., 2019). Moreover, individuals with a history of TBI had significant difficulties in nearly all domains of psychological well-being (Payne et al., 2018).

Implications for Rehabilitation Counselors

Characterizing and understanding psychological well-being in patient populations are important to creating and implementing interventions to improve well-being and have important implications from a rehabilitation perspective. It has been suggested that a better understanding of psychological changes and related factors following a neurological event could improve long-term care (Wijenberg et al., 2019). Longitudinal evidence suggests that short-term emotional well-being in patients with TBI is influenced by individual characteristics and resources (e.g., self-esteem, self-efficacy, and coping styles) and in turn predicts long-term emotional well-being outcomes (Kendall & Terry, 2009). Social and family support also play an important role in short- and long-term emotional well-being following TBI (Kendall & Terry, 2009). In addition, certain character strengths, such as positive affectivity, predict greater physical health and are associated with greater life satisfaction following TBI (Hanks et al., 2014). Similarly, perceived self-efficacy influences the well-being being of stroke survivors (Maujean & Davis, 2013). Bolstering or targeting individual characteristics, including self-esteem, self-efficacy, coping styles, personality traits, and personal values during rehabilitation, may offer a point of intervention to enhance psychological and functional outcomes following a neurological event. In fact, the emphasis on human strengths and assets to promote well-being in the face of disability is a cornerstone of rehabilitation psychology (Chan et al., 2009; Chou et al., 2013; Dunn & Dougherty, 2005).

Both state and trait components are important to well-being (Schimmack et al., 2010; Schimmack & Lucas, 2010). In healthy populations, psychological well-being has been shown to be stable over time (Costa et al., 1987; Kozma, 2000; Lucas & Donnellan, 2007; Mann et al., 2021; Ryff, 1989). The trait-like nature of psychological well-being is not unlike that of personality measures; in fact, personality disposition has been suggested to be a determinant of well-being levels (Costa et al., 1987). Like personality, psychological well-being may be subject to some shifts over the course of a lifespan, but generally demonstrates such adaptability within an overall pattern of stability (Mann et al., 2021). Psychological well-being demonstrates different levels of consistency over different time periods, with longer-term research demonstrating more stable results (Kozma et al., 2000). This suggests that while psychological well-being may appear more state-like in the short term, when looked at longitudinally, trait-like consistency becomes apparent. To date, little is known about the stability of psychological well-being over time in patients who have experienced a major neurological event. Understanding psychological well-being in patient populations may be particularly important to maximizing long-term well-being outcomes following a neurological event.

This Study

This study aims to assess the stability of psychological well-being in the chronic phase of recovery following a neurological event. In addition, given the current pandemic, in a subset of patients we examined the stability of psychological well-being in the face of an extreme and prolonged global disaster. The idea of trait-like stability is particularly fascinating in the context of major, life-altering events such as the COVID-19 pandemic. Lives worldwide have been dramatically disrupted: from record numbers of people working from home, to isolation from loved ones, to the loss of more than 5 million lives globally, according to the World Health Organization (https://covid19.who.int/). Many people experienced dramatic lifestyle shifts in areas such as physical activity, screen time, and sedentary behavior (Meyer et al., 2020). Although psychological well-being may not be expected to remain stable in the wake of such events, research has indicated surprisingly high levels of stability. The World Happiness Report is an annual study which examines several factors related to the emotional state of the world. In the 2021 report, authors were surprised to see that while there were some short-term dips during the beginning of the pandemic, global life evaluations and happiness rankings generally showed remarkable resilience and astonishing stability in the context of COVID-19 (Helliwell et al., 2021). However, whether this stability holds true for individuals living with brain damage is unknown.

In the current work, we hypothesized that psychological well-being, given its trait-like characteristics, would remain stable over time in the chronic phase of recovery following a neurological event. Participants completed the Ryff PWBS, comprised of six domains of well-being (Ryff, 1989; Ryff & Keyes, 1995), twice between 2016 and 2020. This measure of well-being was selected as it captures aspects of well-being beyond happiness per se. Furthermore, the six domains of well-being being comprising this measure—autonomy, environmental mastery, personal growth, positive relations with other, purpose in life, and self-acceptance—may be particularly important in the context of rehabilitation and recovery following a neurological event. Test–retest reliability for each domain of well-being and for overall well-being was evaluated. In addition given that the pandemic struck in the middle of data collection for this study, supplemental exploratory analyses were conducted to examine the effect of a global pandemic on the stability of well-being in this population. This work provides new insights into the long-term stability of psychological well-being in patients who have experienced a neurological event, and also sheds light on the effects of a global pandemic on well-being in this population.

Materials and Method

Participants

Eighty participants (women = 40) between the ages of 24 and 76 (M = 56, SD = 13) were recruited through the Neurological Patient Registry (Tranel, 2019) at a major university-affiliated academic medical center in the Midwestern United States. To determine appropriate sample size, power analyses were conducted using extant literature examining psychological well-being in adult populations. The effect size of psychological well-being was estimated to be between r = .3 and r = .4. In order to have 80% power to detect a significant result given this effect size, a sample of between 52 and 90 was needed. Therefore, the current sample of 80 was deemed appropriate.

Inclusion and Data Collection

All patients experienced a discrete neurological event resulting in permanent focal, stable brain damage. Detailed neuropsychological and neuroanatomical data were collected for these patients, using the Benton Neuropsychology Laboratory and Laboratory of Brain Imaging and Cognitive Neuroscience standard protocols (Barrash et al., 2011; Tranel, 2009). All participants gave written informed consent at the time of their enrollment in the Patient Registry, and the study was approved by the university Institutional Review Board. All data used in this study were obtained in the chronic epoch of recovery, when psychological, behavioral, and cognitive status as related to an acute neurological event have stabilized. Specifically, following a neurological event such as a stroke, the acute phase of recovery lasts for approximately 3 months—during this time, there can be substantial changes (improvements) in both cognitive/behavioral functioning and in neuroanatomical status. After that time, changes tend to be minimal, and patients are considered “stable,” both behaviorally and neuroanatomically (Damasio, 2000). This convention for defining the “chronic epoch” has been used extensively in previous research (Tranel, 2019).

Table 1 provides detailed demographic information for the full sample. Further analyses were conducted with participants divided into two subgroups: those who completed the T2 assessment before the official beginning of the COVID-19 global pandemic on March 11, 2020, and those who completed it after that date (i.e., during the pandemic). Detailed demographic information for these subgroups can be found in Table 2.

Table 1.

Demographic Characteristics (N = 80).

	M (SD)	Min	Max	Lesion etiology	n	Vocational status	n	Marital status	n
T1 age	56.05 (13.01)	24	76	Stroke	35	Full-time	27	Married	58
T2 age	59.78 (13.12)	28	80	Resection	42	Part-time	10	Divorced	12
Years of education	12.83 (2.40)	10	20	Focal contusion	1	Retired	26	Widowed	4
Time (yrs) since onset (T1)	12.75 (10.17)	0	58	Encephalitis	2	Disabled	19	Never married	17
Time (yrs) since onset (T2)	16.75 (10.17)	4	62			Unemployed	4	Unemployed	4
Full-scale IQ	105.07 (14.65)	74	136			Other	5	Other	5
Gender	F = 40	M = 40

Table 2.

Demographic and Intellectual Characteristics by T2 Completion Date Relative to COVID.

	T2 pre-COVID (N = 38)					T2 during-COVID (N = 42)
	M (SD)	Min	Max	Lesion etiology	n	M (SD)	Min	Max	Lesion etiology	n
T1 age	58.55 (12.16)	27	75	Stroke	21	53.26 (13.22)	24	76	Stroke	14
T2 age	62.34 (12.32)	31	79	Resection	15	56.92 (13.96)	28	80	Resection	27
Years of education	15.10 (2.29)	12	20	Focal contusion	0	14.61 (2.51)	10	20	Focal contusion	1
Time (yrs) since onset (T1)	18.86 (10.21)	8	58	Encephalitis	2	7.15 (5.95)	0	23	Encephalitis	0
Time (yrs) since onset (T2)	22.86 (10.21)	12	62			11.15 (5.95)	4	27
Full-scale IQ	109.97 (11.92)	74	136			99.00 (15.62)	79	133
Gender	W = 20	M = 18				W = 20	M = 22

Measures

Participants completed the Ryff PWBS (Ryff, 1989) at two time points (T1 and T2). The PWBS is a measure used to assess psychological well-being, operationalized along six dimensions: self-acceptance (e.g., “I like most aspects of my personality”), purpose in life (e.g., “I am an active person in carrying out the plans I set for myself”), personal growth (e.g., “I think it is important to have new experiences that challenge how you think about yourself and the world”), positive relations with others (e.g., “People would describe me as a giving person, willing to share my time with others”), environmental mastery (e.g., “In general, I feel I am in charge of the situation in which I live”), and autonomy (e.g., “I have confidence in my opinions, even if they are contrary to the general consensus”) (Ryff, 1989). This measure has been shown to be both reliable and valid and has been used in hundreds of empirical investigations, across diverse populations. The six dimensions of well-being which make up the scales have withstood extensive psychometric scrutiny and have been translated into more than 30 different languages (Ryff, 2014).

In the initial validation study of the scales (Ryff, 1989), each dimension of well-being was operationalized with 20 items, showing high internal consistency and test–retest reliability as well as convergent and discriminant validity with other measures of positive functioning. This study used a shorter, 84-item version of the measure, as recommended by Ryff and colleagues (via personal correspondence). Internal consistency and correlation with the parent 20-item scales for each dimension of the measure are as follows: Self-acceptance: internal consistency (coefficient alpha) = .91, correlation with 20-item parent scale = .99; Purpose in life: internal consistency (coefficient alpha) = .88, correlation with 20-item parent scale = .98; Personal growth: internal consistency (coefficient alpha) = .85, correlation with 20-item parent scale = .97; Positive relations with others: internal consistency (coefficient alpha) = .88, correlation with 20-item parent scale = .98; Environmental mastery: internal consistency (coefficient alpha) = .86, correlation with 20-item parent scale = .98; and Autonomy: internal consistency (coefficient alpha) = .83, correlation with 20-item parent scale = .97.

Each dimension of the short-form measure consists of 14 items. Participants respond using a six-point rating scale, where 1 = strongly disagree; 2 = moderately disagree; 3 = slightly disagree; 4 = slightly agree; 5 = moderately agree; and 6 = strongly agree. Half of the items on the scale are negatively worded and are, therefore, reverse scored (e.g., 6 = 1, 5 = 2, and 4 = 3) in the final scoring procedures so that for all scales, high scores indicate high self-ratings on the dimension assessed. Scores for each dimension of the measure range from 14 to 84. Total psychological well-being scores were calculated by adding the scores across all six domains and ranged from 84 to 504.

All participants also completed a questionnaire to collect demographic information.

Procedures

For participation at T1, individuals were mailed a letter detailing this study and a copy of the PWBS. All participants were invited to participate in the study by mailing back a completed copy of the scales. In total, 283 scales were sent out, 60 scales were returned to sender (due to incorrect address or other complications), and 222 scales successfully reached their destinations. In total, 132 scales were completed by 2018.

For participation at T2, all neurological patients who participated at T1 were contacted via phone, mail, or e-mail and asked to complete the PWBS again and to provide additional demographic information. Participants completed the scales either online (n = 30), via mail (n = 39), or over the phone (n = 11). For those who completed the scales via phone, trained research assistants contacted the individuals and read each item of the questionnaire to them. Research assistants were trained to clearly explain the questionnaire instructions and rating scale to the participants, and participants were asked to write the rating scale on a piece of article and keep it nearby for reference. One participant was not able to complete the questionnaire via phone, and, therefore, the interview was discontinued and the participant’s data were excluded. In all other cases, there was no indication of any participant having confusion or difficulty when conducting the questionnaire via phone. Of the 132 individuals who participated at T1, 80 people participated again at T2. Thus, in the total sample of 80 people, the PWBS were collected at T1 in 2016 (n = 65), 2017 (n = 8), or 2018 (n = 7). Data collection continued over the course of multiple years until we exhausted the participant registry and had no more patients to contact. T2 participation occurred during 2020. Cronbach’s alpha was acceptable for each domain of well-being at both data collection time points (ranging from .89 to .90 at both T1 and T2), indicating good internal consistency regardless of data collection methodology.

It is important to mention that on March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. Given the timing of this event, 38 participants completed their 2020 (T2) assessment before the pandemic onset and 42 completed it after. Overall, the interval between assessments had a mean of 3.73 years (SD = .61).

Data Analysis

All data were examined and evaluated for outliers and normality, using data visualization techniques and measures of skewness and kurtosis. All data were in range. For data collected at T2, two participants showed scores that were consistent outliers on various domains of well-being. Therefore, analyses were conducted with and without these participants. Results remained largely unchanged and, therefore, the full sample was retained and the corresponding results were reported here. Data largely conformed to a normal distribution and statistical analyses that are highly robust even in non-normal distributions were used.

To examine the stability of psychological well-being over time, correlations between T1 scores and T2 scores were examined using Pearson’s R for each domain of well-being and for the total score. Paired t-tests were used to further investigate these comparisons and check for differences in scores between the two time points. Parallel analyses were then conducted to examine any effects of the pandemic on the stability of psychological well-being over time. Specifically, correlations between T1 and T2 were conducted separately among the participants whose T2 scores were collected after the onset of the COVID-19 global pandemic. Paired t-tests were utilized to further investigate these comparisons as well. In addition, comparisons of changes in psychological well-being over time and unpaired t-tests were conducted to further investigate whether the specific timing of the T2 assessment during the pandemic (e.g., closer to the beginning versus further along in the pandemic) played a role in stability in patients who completed T2 after the start of COVID.

Results

Statistical analysis revealed strong, statistically significant correlations between T1 and T2 for all domains of psychological well-being, as well as for total scores (see Figures 1–7). Paired t-tests revealed no significant differences between mean T1 and T2 scores (see Table 3). Figures 1–6 demonstrate that individual well-being domain scores at T1 were all strongly correlated with scores at T2, and there were no significant differences between mean level well-being domains at T1 compared with T2. Overall, total psychological well-being scores at T1 and at T2 were also strongly correlated, r = .87, p < .05, 95% confidence interval (CI) [0.80, 0.92], and there was not a significant difference between mean levels of self-reported total psychological well-being at T1 (M = 390.06, SD = 62.31) compared with T2 (M = 391.81, SD = 63.59; see Figure 7). In fact, the T1 and T2 means were numerically almost identical.

Figure 1.

Relationship Between Autonomy at T1 and T2.

Note. Autonomy scores for T1 (M = 63.7, SD = 8.77) compared with T2 (M = 64.8, SD = 9.25).

Figure 2.

Relationship Between Environmental Mastery at T1 and T2.

Note. Environmental mastery scores for T1 (M = 64.53, SD = 13.77) compared with T2 (M = 65.10, SD = 13.66).

Figure 3.

Relationship Between Personal Growth at T1 and T2.

Note. Personal growth scores at T1 (M = 66.69, SD = 10.29) compared with T2 (M = 67.74, SD = 11.00).

Figure 4.

Relationship Between Positive Relations With Others at T1 and T2.

Note. Positive relations with others scores at T1 (M = 64.60, SD = 13.31) compared with T2 (M = 64.58, SD = 13.13).

Figure 5.

Relationship Between Purpose in Life at T1 and T2.

Note. Purpose-in-life scores at T1 (M = 65.63, SD = 13.02) compared with T2 (M = 65.16, SD = 13.59).

Figure 6.

Relationship Between Self-acceptance at T1 and T2.

Note. Self-acceptance scores at T1 (M = 64.93, SD = 14.63) compared with T2 (M = 64.44, SD = 15.81).

Figure 7.

Relationship Between Total Well-being at T1 and T2.

Note. Total well-being scores at T1 (M = 390.06, SD = 62.31) compared with T2 (M = 391.81, SD = 63.59).

Table 3.

Psychological Well-being (N = 80).

Domain of psychological well-being	T1 score	T2 score	Paired t-test			Correlation
	M (SD)	M (SD)	t(df)	p	CI	r
Autonomy	63.70 (8.77)	64.80 (9.25)	−1.43 (79)	0.1558	[−2.62, 0.43]	0.712*
Environmental mastery	64.53 (13.77)	65.10 (13.66)	−0.65 (79)	0.5192	[−2.34, 1.19]	0.834*
Personal growth	66.69 (10.29)	67.74 (11.00)	−1.49 (79)	0.1394	[−2.45, 0.35]	0.828*
Positive relations with others	64.60 (13.31)	64.58 (13.13)	0.031 (79)	0.9752	[−1.57, 1.62]	0.854*
Purpose in life	65.63 (13.02)	65.16 (13.59)	0.51 (79)	0.6092	[−1.33, 2.26]	0.818*
Self-acceptance	64.93 (14.63)	64.44 (15.81)	0.54 (79)	0.5933	[−1.32, 2.29]	0.860*
Total psychological well-being	390.06 (62.31)	391.81 (63.59)	−0.49 (79)	0.6278	[−8.91, 5.41]	0.870*

Note. CI = confidence interval.

^*p < .0001.

Additional analyses were conducted to account for possible covariates, including the chronological age of participants on the date they completed the psychological well-being measure (age at testing), gender, and time since neurological event (chronicity). Specifically, we examined differences in well-being between men and women (see Table 4) and ran partial correlations to consider gender, age at testing, and chronicity as possible covariates (see Table 5). Psychological well-being remained stable even when accounting for these additional factors. There were strong, significant correlations among all domains of well-being in both genders. Partial correlations accounting for age at testing, gender, and chronicity also remained high and significant across all well-being domains.

Table 4.

Psychological Well-being and Gender.

Men	T1 score	T2 score	Paired t-test			Correlation
Domain of psychological well-being	M (SD)	M (SD)	t(df)	p	CI	r
Autonomy	67.2 (7.02)	67.9 (6.84)	−0.73 (38)	0.466	[−2.78, 1.30]	0.586*
Environmental mastery	67.3 (14.4)	67 (14.7)	0.25 (38)	0.799	[−2.12, 2.73]	0.867*
Personal growth	67.4 (10.4)	68.8 (10.9)	−1.26 (38)	0.217	[−3.54, 0.83]	0.801*
Positive relations with others	64.4 (13.1)	64.8 (12.9)	−0.43 (38)	0.672	[−2.50, 1.63]	0.879*
Purpose in life	67.7 (12.8)	67.7 (14.1)	−0.05 (38)	0.959	[−2.07, 1.97]	0.896*
Self-acceptance	67.9 (13.7)	67 (15.2)	0.82 (38)	0.417	[−1.43, 3.38]	0.873*
Total psychological well-being	402 (62.3)	403 (62.8)	−0.29 (38)	0.767	[−10.19, 7.51]	0.904*
Women	T1 score	T2 score	Paired t-test			Correlation
Domain of psychological well-being	M (SD)	M (SD)	t(df)	P	CI	r
Autonomy	60.4 (9.28)	61.5 (10.2)	−1.02 (39)	0.316	[−3.51, 1.16]	0.722*
Environmental mastery	61.7 (13)	63.5 (12.6)	−1.35 (39)	0.184	[−4.36, 0.86]	0.797*
Personal growth	65.9 (10.5)	66.5 (11.2)	−0.69 (39)	0.492	[−2.54, 1.24]	0.852*
Positive relations with others	64.5 (13.9)	64.1 (13.6)	0.32 (39)	0.754	[−2.16, 2.96]	0.831*
Purpose in life	63.4 (13.3)	62.5 (12.9)	0.61 (39)	0.548	[−2.18, 4.01]	0.728*
Self-acceptance	61.8 (15.4)	61.8 (16.3)	0.02 (39)	0.986	[−2.83, 2.88]	0.842*
Total psychological well-being	378 (62.1)	380 (63.6)	−0.38 (39)	0.705	[−14.03, 9.58]	0.827*

Note. CI = confidence interval.

^*p < .0001.

Table 5.

Examining Covariates Related to Psychological Well-being.

Domain of psychological well-being	Partial correlations
	Gender r	Age at testing r	Chronicity r
Autonomy	0.676*	0.714*	0.721*
Environmental mastery	0.836*	0.836*	0.855*
Personal growth	0.828*	0.831*	0.835*
Positive relations with others	0.854*	0.856*	0.859*
Purpose in life	0.812*	0.851*	0.822*
Self-acceptance	0.856*	0.854*	0.860*
Total psychological well-being	0.865*	0.868*	0.878*

Note. Age at testing refers to the chronological age of participants on the date they completed the psychological well-being measure. Chronicity refers to time since neurological event.

Follow-up analyses were conducted to examine psychological well-being within the subset of patients who completed the T2 assessment prior to COVID (“T2 pre-COVID” group) and those who completed the T2 assessment during COVID (“T2 during-COVID” group). Paired t-tests showed no differences in mean reported levels of psychological well-being between T1 and T2 for either group. Both the T2 pre-COVID and T2 during-COVID groups showed strong, statistically significant correlations between T1 and T2 in all domains of psychological well-being (see Table 6).

Table 6.

Psychological Well-being and COVID-19.

T2 pre-COVID group	T1 score	T2 score	Paired t-test			Correlation
	M (SD)	M (SD)	t(df)	p	CI	r
Autonomy	64.21 (8.43)	64.28 (10.35)	−1.12 (37)	0.272	[−3.26, 0.95]	0.696*
Environmental mastery	66.57 (13.01)	63.11 (14.87)	−0.62 (37)	0.539	[−3.03, 1.61]	0.843*
Personal growth	67.84 (9.50)	67.45 (11.08)	−0.21 (37)	0.539	[−2.25, 1.83]	0.827*
Positive relations with others	65.13 (14.21)	62.40 (13.22)	−1.78 (37)	0.083	[−3.94, 0.25]	0.893*
Purpose in life	67.58 (12.31)	62.31 (15.13)	−0.57 (37)	0.571	[−3.35, 1.88]	0.773*
Self-acceptance	66.13 (14.80)	62.21 (17.56)	−0.66 (37)	0.513	[−3.11, 1.58]	0.876*
Total psychological well-being	397.47 (60.83)	381.78 (68.96)	−1.05 (37)	0.300	[−15.86, 5.02]	0.855*
T2 during-COVID group	T1 score	T2 score	Paired t-test			Correlation
	M (SD)	M (SD)	t(df)	p	CI	r
Autonomy	63.24 (9.34)	65.36 (7.94)	−0.69 (40)	0.493	[−3.06, 1.50]	0.735*
Environmental mastery	62.54 (14.65)	67.29 (11.99)	−0.56 (40)	0.578	[−3.48, 1.97]	0.831*
Personal growth	65.54 (11.21)	68.05 (11.05)	−1.73 (40)	0.091	[−3.75, 0.29]	0.836*
Positive relations with others	63.85 (12.81)	66.97 (12.77)	1.42 (40)	0.164	[−0.72, 4.08]	0.831*
Purpose in life	63.56 (13.72)	68.31 (11.02)	−1.20 (40)	0.237	[−1.05, 4.12]	0.844*
Self-acceptance	63.66 (14.90)	66.89 (13.41)	−1.18 (40)	0.244	[−1.17, 4.49]	0.862*
Total psychological well-being	382.39 (64.84)	402.89 (55.87)	0.31 (40)	0.756	[−8.79, 12.01]	0.882*

Note. CI = confidence interval.

^*p < .0001.

Within-subject change scores from T1 to T2 were calculated for each participant to examine any differences in the pattern of change in well-being across time between the pre-COVID and during-COVID groups (see Table 7). Unpaired t-tests revealed no significant differences between the two groups, indicating that change in well-being from T1 to T2 was similar across groups.

Table 7.

Change in Psychological Well-being Scores and COVID-19.

Domain of psychological well-being	T2-T1 change scores M (SD)		Unpaired t-test
	T2 pre-COVID	T2 during-COVID	t(df)	p	CI
Autonomy	1.16 (6.40)	2.25 (13.49)	−0.59 (59.83)	0.553	[−6.04, 3.26]
Environmental mastery	0.71 (7.06)	2.07 (12.05)	−0.62 (67.29)	0.535	[−5.72, 2.99]
Personal growth	0.21 (6.21)	3.48 (12.95)	−1.46 (60.17)	0.150	[−7.74, 1.21]
Positive relations with others	1.84 (6.37)	0.07 (13.62)	0.75 (59.38)	0.453	[−2.91, 6.46]
Purpose in life	0.74 (7.95)	0.26 (14.19)	0.19 (65.63)	0.850	[−4.60, 5.55]
Self-acceptance	0.76 (7.13)	0.07 (14.30)	0.27 (61.49)	0.780	[−4.29, 5.67]
Total psychological well-being	5.42 (31.75)	8.5 (73.15)	−0.25 (57.11)	0.805	[−27.92, 21.77]

Note. CI = confidence interval.

Given the rapidly changing nature of the COVID pandemic, it was important to investigate whether the timing of the T2 assessment influenced levels of well-being in the “T2 during-COVID” group. As illustrated in Figures 8 and 9, variability in well-being remained consistent over time. These plots show that the timing of the T2 measurement during the pandemic did not appear to systematically affect levels of self-reported well-being. Our data are limited by the fact that most of the T2 assessments in the post-COVID group were obtained between March and May. However, we did have some assessments as far out as August, and as Figures 8 and 9 show, there is no strong evidence that the later assessments are associated with more change in well-being.

Figure 8.

T2 Well-being Scores Across Months.

Note. Scores for each domain of psychological well-being organized by assessment date.

Figure 9.

T2 Total Well-being Scores Across Months.

Note. T2 Total scores for during-COVID group organized by assessment date.

Discussion

This study suggests that psychological well-being among patients who are in the chronic phase of recovery following a major neurological event is highly consistent over time. Furthermore, the timing of this study in relation to the COVID-19 pandemic allowed us to study how well-being among this population fared in light of an unprecedented global disaster. We found that consistency of well-being held even among patients whose second assessment occurred during the pandemic.

Well-being is a complex construct that is considered to have trait-like characteristics but can also be affected by acute environmental factors (Anusic & Schimmack, 2016; Schimmack et al., 2010). Previous research examining the consistency of well-being has shown that well-being tends to be stable over time among healthy adults (Costa et al., 1987; Mann et al., 2021; Ruini et al., 2003; Ryff, 1989; Ryff et al., 2015). The current work supports and extends past findings, providing initial evidence that psychological well-being is remarkably stable over the course of 4 years in a group of patients who have experienced a major neurological event, such as a stroke, tumor resection, or traumatic brain injury.

Comparability to Healthy Populations

Importantly, this work specifically addresses the issue of stability of psychological well-being in patients who have experienced a neurological event. Broader issues, such as what psychological well-being looks like in neurological patients compared with healthy persons per se, the trajectory of changes in well-being over the course of recovery in neurological patients (e.g., at a more granular level than we studied, for instance, every month or every several months after the onset of a neurological injury), and the neuroanatomical correlates of well-being, remain open areas of investigation (beyond the scope of the present work).

Our study suggests that in patients with focal brain damage, psychological well-being is a stable, trait-like attribute, comparable to what is seen in healthy adult individuals without neurological injuries. These findings are in line with past work showing similar levels of health-related quality of life in patients with strokes (1-year poststroke) and healthy populations (de Weerd et al., 2011). Additional work is needed to directly investigate remaining questions including what stability of well-being looks like in neurological patients compared with healthy persons per se and how other individual difference variables relevant to patients with neurological damage, such as lesion etiology and lesion location, might affect psychological well-being and its stability in this population.

Stability During-COVID-19

The onset of the COVID-19 pandemic occurring during data collection for this study provided a unique opportunity to assess whether and how well-being in patients with focal brain damage changed in the context of a global crisis. One might expect well-being to fluctuate in light of this event, as the pandemic has been linked to marked increases in psychological distress and mental health problems (Krishnamoorthy et al., 2020; Luo et al., 2020). However, our findings suggest that well-being remained consistent even after the onset of the pandemic. This lends support to the idea that psychological well-being is, at least in part, an enduring psychological attribute. We would hasten to add that most of our post-COVID measurements were in the several months immediately after the start of the pandemic (March–May 2020) (although we did have several measurements in persons out to August 2020), and it is an open question as to whether well-being would change over a longer time course in patients who were assessed after the onset of the pandemic.

Stable, But Not Static

This work makes an important contribution to the literature by providing evidence that psychological well-being is reliable and consistent over time in the chronic phase of recovery following a neurological event, supporting the idea that psychological well-being has trait-like characteristics (Costa et al., 1987; Kozma, 2000; Lucas & Donnellan, 2007; Mann et al., 2021; Ryff, 1989). However, it is important to remember that stable does not mean static (Dawn & Ownsworth, 2019; Payne et al., 2018). Although potentially counterintuitive at first glance, we can turn to current understandings of blood pressure as a useful analogy to help explain the stable but potentially changeable nature of psychological well-being. Blood pressure is considered a stable trait, unlikely to undergo drastic changes over time (Hottenga et al., 2005). However, blood pressure may be strongly impacted by acute stressors and can undergo transient fluctuations. The same logic applies to psychological well-being: It is both highly stable and subject to transient changes from factors such as acute stressors (Mann et al., 2021).

Implications for Rehabilitation

In the context of rehabilitation from neurological injury, the current work has several implications. Psychological well-being can be improved through proper interventions (Dupont et al., 2020; Trudel-Fitzgerald et al., 2019). Meta-analytic data examining the effectiveness of positive psychology interventions have shown that interventions targeting optimism, gratitude, mindfulness, and kindness can result in clinically meaningful improvements in psychological well-being (see Trudel-Fitzgerald et al., 2019 for review). Additional interventions include mind–body exercise like yoga, and well-being therapy (Fava et al., 2017; Love et al., 2019).

An interdisciplinary approach can aid in providing the treatment needed to address psychological well-being in a rehabilitation setting. Willingness to work with or provide referrals to psychologists or therapists who are equipped to address psychological distress or low well-being in patients may help to round out their care (Sekhon et al., 2015). Positive psychology has been shown to be an effective approach in the rehabilitation of those with severe disability, as identification and development of strengths can help to build the psychological well-being domains of autonomy, purpose in life, and self-acceptance (Chou et al., 2013). Group therapy has also demonstrated psychological benefits in some neurological populations, and research which investigates its effectiveness in bolstering psychological well-being among those with focal brain damage would be highly worthwhile (Sekhon et al., 2015). Therapies and programs which take place in a group setting are particularly promising avenues for addressing psychological well-being, as they can help to create a sense of community and purpose, as well as provide socialization. Prior research suggests that the psychosocial benefits of these groups may increase well-being (Hoen et al., 1997).

We should be clear here that the premise for rehabilitation and intervention vis-à-vis well-being is that well-being is modifiable, at least in the short term, even if it resembles a trait-like attribute over long periods of time. For example, in the early period after the onset of a neurological injury, patients may experience a significant drop in well-being, and interventions at this stage could be very beneficial—for example, hastening the recovery process, facilitating participation in physical, occupational, and cognitive therapies, and enhancing the patient’s sense of mastery over their recovery trajectory. Thus, despite the trait-like nature of well-being, it remains very much the case that well-timed interventions could be very helpful. This is a promising area for additional research with brain-injured persons.

When treating persons who have experienced a neurological event, considering psychological well-being in treatment could be vital in creating the best possible quality of life. Moreover, proposed interventions could occur on the individual level and on a public health level. For example, it has been suggested that policy interventions could help to positively shape the psychological well-being of a community through government-supported resources (Dupont et al., 2020; Trudel-Fitzgerald et al., 2019).

In the context of the current global pandemic, evidence suggests that high well-being can act as a buffer in times of increased stress (Dupont et al., 2020; Kubzansky et al., 2018). Future research could investigate well-being interventions as a form of upstream prevention. For instance, public health interventions implemented to boost well-being may better prepare populations for events like COVID-19, potentially lessening the increase in psychological morbidities and reducing the strain on mental health infrastructure.

Limitations

There are important limitations to our work. Our participants were geographically and racially homogeneous, with most of the participants being white Midwesterners. Additional research could be done to investigate whether our findings hold among more diverse populations. Furthermore, there may be a selection bias at play, since participants opted into this study. Their willingness to participate in research, especially a study that is occurring over a long period of time, is a shared characteristic which may be related to psychological well-being. However, it is unlikely that this potential selection bias impacted the results of this study in a major way, as well-being scores for our participants were normally distributed and included people at widely varying levels of well-being. Nonetheless, further research should investigate whether psychological well-being looks similar among populations who do not have the time, resources, or desire to participate in a study of this nature. Also, we did not have data to address in this study how injury severity or the degree of disability following a neurological event impacts the stability psychological well-being. In individuals who sustained TBI, current literature has suggested both positive and negative associations between injury severity and psychological well-being, which are often subject to mediation by other variables, including personality and social factors (Jones et al., 2011; Kalpinski et al., 2013). Additionally, most of the participants in our study (77 of 80) incurred their neurological injury from stroke or surgical resection (as opposed to traumatic brain injury), making it difficult to draw direct comparisons to the literature on TBI. Nonetheless, furthering our understanding of how degree of disability and severity of injury are related to both short- and long-term stability of psychological well-being is an important avenue for future research and should be addressed in patients with a variety of etiologies. Lastly, our ability to make inferences regarding the effect of COVID-19 on the stability of psychological well-being is limited, as the bulk of T2 assessments in the “T2 during-COVID” group occurred in the first several months after the onset of the pandemic.

Conclusion

Overall, the current work provides the first characterization, to our knowledge, of the stability of psychological well-being in the chronic epoch of recovery following focal brain injury. Future work is needed to address outstanding questions that go beyond the scope of this work, such as characterizing well-being in neurological populations compared with other medical populations and healthy populations, as well as examining the psychological, behavioral, and neural correlates of well-being in neurological populations. Providing evidence that long-term well-being is stable and trait-like in this population, however, is an important step in expanding the current understanding of psychological well-being. In addition, our unique opportunity to examine well-being in the context of COVID-19 yielded additional evidence that psychological well-being is a consistent and trait-like measure, even in the face of a global pandemic.