Interventions for self-awareness

Decreased awareness of TBI-related deficits can be the result of neurologically based

anosognosia and/or psychogenic denial. Regardless of etiology, the treatment of poor awareness
of deficits is vital to the success of cognitive rehabilitation because a clinician generally cannot
effectively treat a symptom the patient does not notice. Consistent with this, diminished self-
awareness has been associated with poor rehabilitation outcome. In contrast, increasing
awareness of deficits can result in psychological distress. Several models exist that explain
impaired self-awareness due to TBI. Crosson et alintroduced the pyramid model of awareness,
which distinguishes between intellectual awareness (the ability to understand that there are
certain deficits in functioning), emergent awareness (the ability to recognize a functional
problem when it occurs), and anticipatory awareness (the ability to predict that an area of deficit
may lead to problems in functioning). Other models include Langer and Padrone’s tripartite
model of unawareness: unawareness of information, unawareness of implications, and
psychological denial; Fleming and Ownsworth’s model of awareness of objective knowledge:
awareness of the functional implications of deficits for daily activities and the ability to set
realistic goals; and Allen and Ruff’s56 model, which includes the ability to attend to, encode,
and retrieve information about the self, the ability to compare current and premorbid functioning,
and willingness to report self-perception to another person. Finally, Giacino and
Ciceroneidentified three sources for limited awareness: cognitive impairment (especially
attention, memory, and self-monitoring), psychogenic denial, and failure of higher-order
cognitive systems to recognize deficits and incorporate them in self-knowledge. In addition to
the neurocognitive and psychological sources of unawareness typically described in these
models, Fleming and Ownsworth identified social-environmental factors that contribute to
diminished awareness. These factors include minimal opportunities to obtain information or to
observe deficits in a social context, reluctance to disclose information about the deficits due to
concerns about how the information will be used, and the interference of cultural values with the
neuropsychological rehabilitation process. Neuropsychological interventions to treat self-
awareness deficits include milieu-oriented treatment programs aimed at increasing awareness via
peer, staff, and family feedback; psycho-education and psychotherapy; and cognitive remediation
interventions, such as therapist monitoring of task performance and generating lists of strengths
and weaknesses. These interventions are based on the idea that unawareness of deficits can have
both a neurological and psychological origin (e.g., as the result of a defensive coping style). In a
randomized clinical trial to improve executive function described in a previous section,94 the
investigators have observed significant improvements in self-awareness. Although anecdotal, the
investigators attribute the observed improvement to comprehensive treatment involving both
individual and group sessions emphasizing metacognitive training with the group sessions
allowing participants to observe deficits in others and share challenges (e.g., “what he is saying
has also happened to me”). Psychotherapeutic interventions for lack of awareness of deficits are
aimed at exploring the meaning of loss following TBI and ameliorating the effects by developing
meaningful and realistic goals. Langer and Padrone’stripartite model of unawareness provides a
useful framework for developing psychotherapeutic interventions to raise awareness. Within this
model, interventions to increase awareness of deficits include psycho-education and feedback
about the individual’s TBI-related impairments. Interventions to increase awareness of the
implications include building a supportive structure to allow the individual to learn
compensatory strategies and avoid failures. Interventions to address the psychological denial
include assessing the client’s readiness to recognize deficits and to strengthen their tolerance for
resulting distress. Interventions based on Crosson et al.’s pyramid model have included psycho-
education, feedback, planned failures, and emotional support to increase intellectual awareness,
feedback during and after task completion to increase emergent awareness, and helping the
individual create plans and anticipate problems to raise anticipatory awareness. Self-
determination is an approach based on the pyramid model that includes education, practice in
safe and structured environments, and application in real-life situations. Other interventions to
increase self-awareness have included structured experiences, direct feedback, support groups,
and a game format. Structured experiences are preplanned and personalized exercises to increase
awareness, metacognitive knowledge, and self-efficacy. Techniques including anticipation of
obstacles, self-prediction, selfchecking, self-questioning and self-evaluation, time-monitoring,
and role-reversal are used in the duration of the structured experience. Direct feedback involves
the therapist’s commentary on the individual’s task performance. Direct feedback is beneficial
when it is specific, timely, consistent, and respectful and when the unawareness is neurological
rather than psychogenic. Finally, support groups and games that provide education about brain
injury and its sequelae can be used to improve awareness in a nonconfrontational manner, but the
impact of these experiences on individuals’ self-appraisal ability is inconsistent.

FUTURE DIRECTIONS IN NEUROPSYCHOLOGICAL REHABILITATION

Technology and neuropsychological rehabilitation Technological aids have been employed in the
treatment of individuals with cognitive deficits since the early days of cognitive rehabilitation.
Use of computers to project visual and verbal stimuli to provide training in attention, memory,
processing speed, and problem solving has become commonplace over the past decade. Over
time, technology in neuropsychological rehabilitation has progressed from the use of computers
as passive tools to facilitate cognitive training to active training tools that could expand the scope
of training as well as compensatory tools or cognitive orthotics that could be used in everyday
settings to support functioning and reduce disability. Examples of technology as training tools
include the use of computers in the training of memory, attention, problem solving, and job
simulation. The advantage of using technology as a training tool is that it permits the
administration of tasks that would otherwise be impossible to administer. However, computer-
assisted training is generally not associated with better outcomes than is therapist-assisted
training. The use of technology to develop compensatory tools has resulted in the creation of
devices that can enable completion of tasks heavily reliant on complex cognitive processesand, at
the same time, result in significant improvements in psychosocial functioning,146 rendering the
individual with TBI more competent in task completion, time management, and record keeping,
while bolstering his or her self-efficacy. Lopresti12 provides an extensive review of existing
technological aids, which he divides into technologies for memory and executive function
impairments and technologies for information processing impairments. Devices for memory and
executive function range from digital watches and alarms to more sophisticated devices, such as
voice organizers (some of which will replay a message aloud at a prespecified time); mobile
phone-computer interactive systems; and handheld devices, such as personal digital assistants.
Devices for information processing impairments include use of a keyboard for typing instead of
writing, software that alters the features of computer text (e.g., size, color) to increase reading
ease, and speech output/ speech recognition software. An additional use of technology includes
teletherapy. Bell et al. tested the effectiveness of telephone interviews on behavioral outcomes.
The content of the phone call was a mixture of counseling, motivational interviewing, and
psycho-education. Their results showed significant improvement in functional measures in those
participants who received telephone counseling compared to those who did not, suggesting that
telephone counseling may be an effective, low-cost, and easily accessible alternative
intervention. Melton and Bourgeois148 assessed the effectiveness of a learning and memory
intervention over the telephone and identified three advantages: 1) increased generalization as
the skill is being learned in the individuals’ everyday environment, 2) increased accessibility to
individuals with TBI who might be otherwise unable to receive treatment due to practical
barriers (e.g., limited transportation, financial constraints, mobility issues, living a distance from
treatment providers), and 3) the potential to reduce absenteeism. Similarly, Tsaousides and
colleagues conducted a pilot study82 to determine the feasibility of delivering an emotion-
regulation skills intervention in a group format to TBI survivors via videoconferencing and
found excellent ease of use, attendance, and self-reported satisfaction and adequate skill
acquisition among participants. The feasibility of delivering this intervention via
videoconferencing is currently being studied in a large-scale study, including participants with
TBIs of varying severities from around the United States and abroad. Study enrollment is limited
to those with clinically significant emotional dysregulation at baseline, and more extensive data
on efficacy is being collected. Data from this study should be available in early 2017. Given
consumer satisfaction with the use of technological devices and the encouraging results from
small-scale studies, it is expected that in the next few years several improvements and
adjustments will be made to create portable electronic devices that will further facilitate daily
functioning in those with TBI. The pervasiveness of technology in all aspects of daily living
suggests that a shift from paper-and-pencil to electronic compensatory tools is imminent. This
transition might be met with resistance, especially from older individuals and those less familiar
with technology, highlighting the need for the field to develop effective methods of introducing
technology to the uninitiated. Use of technological aids may allow individuals to use
compensatory tools more consistently and make these tools more attractive, especially to
younger individuals who might be reluctant to use tools that might identify them to others as
having injury-related deficits. Although the use of technology in TBI rehabilitation is expected to
increase in the next few years, technological aids should not be intended to replace a therapist
but rather to enhance the effectiveness of treatment. Findings from studies showing no advantage
of computer-assisted interventions over traditional interventions illustrate the importance of the
clinician as an active participant in the treatment. Therapists set and maintain the structure of
treatment, determine treatment needs and readiness, provide feedback and guidance, and teach
and reinforce the use of compensatory methods. Therapists also help the patient process
emotional reactions that might otherwise impede daily functioning or progress in rehabilitation,
and they facilitate the inclusion of family or other collaterals in the treatment, which is often
helpful in reinforcing the use of rehabilitation strategies in daily life and maximizing functional
gains. Most importantly, a positive working alliance between therapist and client facilitates
treatment and contributes to successful treatment outcome.

CONCLUSION
Neuropsychological rehabilitation is continually evolving in both principle and practice due to a
growing body of research with ever-increasing methodological rigor, but a grand unifying theory
has yet to be developed. Similarly, a “one size fits all” treatment approach will likely remain
elusive and perhaps rightfully so. Each cognitive rehabilitation patient presents with a unique
combination of injuryrelated deficits, premorbid strengths and weaknesses, life goals, and
personal values and beliefs. Therefore, clinicians must stay current with the literature on
available interventions, evidence for efficacy, and outcomes as a function of patient
characteristics and must flexibly apply interventions with an understanding of the individual
needs and goals of the patient. Ylvisaker points out that there has been a paradigm shift from
more traditional approaches, the goal of which is to “fix” the cognitive problem, to more
contextualized approaches whose goal is to enable individuals to live a fuller life by reducing the
burden caused by the cognitive problems. Wilson stated that We have moved on from the early
days of cognitive rehabilitation with its emphasis on drills and exercises to try to reduce basic
impairments, to a more individualized approach addressing the everyday manifestations of these
impairments, i.e., disabilities and handicaps…Cognitive rehabilitation should focus on real-life,
functional problems, it should address associated problems such as mood and behavioral
problems in addition to the cognitive difficulties and it should involve the person with the brain
injury, relatives and others in the planning and implementation of cognitive rehabilitation. (pp.
98–99) Finding a balance between these two conceptualizations of cognitive rehabilitation
continues to present a challenge, and this challenge underlies the controversies of outcome
measurement, distinction between domain-specific training and generalization, and the apparent
contrast between restoration and compensation. Yet, these controversies continue to stimulate
new innovations by clinicians and researchers, whose work constitutes a quest to find better
ways to help TBI survivors improve their cognitive and emotional functioning in order to regain
their independence.