Brain Injury and Self-Awareness: Denial and Metacognition in Occupational Therapy

Introduction

Brain injury may cause cognitive disabilities that affect one’s self-awareness. One model, the Expanded Awareness Model (Toglia & Kirk, 2000), provides a framework of awareness to guide occupational therapy practice. “In this model, assessment of awareness includes comparing client’s self-rating with rating by a relative/clinician, or by the performance on the neuropsychological tests. The discrepancy between two assessment results is considered as a measure of degree of unawareness.”^[1]Toglia, J., & Kirk, U. (2000). Understanding awareness deficits following brain injury. NeuroRehabilitation, 15(1), 57-70.

Another term for one’s self-awareness of their own thoughts as well as an understanding of such thoughts is called metacognition. Meta means beyond or on top of, so beyond one’s own cognition.

Theory: The Awareness Pyramid

Described by Crosson et. al, the pyramid model for TBI provides conceptual definitions for different levels of awareness, which is believed to be hierarchical. It consists of three levels and at the bottom (and foundational for the higher two levels of awareness), intellectual awareness is knowing that something is impaired. Emergent awareness is being able to recognize a problem as it occurs. And third, anticipatory awareness, is being able to recognize that a problem is likely to occur due to one’s deficit. This model can be useful as it highlights that awareness is more complex than our typical definition used in everyday language. Neuroanatomical studies also support these concepts as no one single part of the brain is activated with “awareness”.^[2]G.P. Prigatano, The problem of impaired self-awareness in neuropsychological rehabilitation, in: Neuropsychological rehabilitation: Fundamentals, innovations, and directions, J. Leon-Carrion, ed., … Reference List

Metacognition and Occupational Therapy

In occupational therapy, an occupation-based approach to training one’s metacognition involves the use of real-life meaningful occupations to help the patient develop self-awareness so that they can appropriately set realistic goals and use appropriate functional strategies.^[3] Fleming , J.M. , and Ownsworth , T. (2006) . A review of awareness interventions in brain injury rehabilitation . Neuropsychol Rehabil , 16 , 474 – 500 .

But can all patients benefit from metacognition? What problems arise with conditions such as traumatic brain injury (TBI) and awareness?

Barriers

Research suggests that as much as 45% of severe TBI cases demonstrate reduced awareness of their deficits. This can be a barrier as patients who are not aware of their deficits may overestimate their ability, resulting in potential harm such as falls, injuries, or other causes of concern.^[4]Flashman, L. A., & McAllister, T. W. (2002). Lack of awareness and its impact in traumatic brain injury. NeuroRehabilitation, 17(4), 285-296.

Denial

As you can imagine, not all patients will be happy to accept or even acknowledge that they have deficits, or even one of their own awareness for that matter. Psychologically, denial is seen as a coping strategy to limit one’s own impact from accepting their cognitive limitations.^[5]D.M. Nockleby and A.V. Deaton, Denial vs. distress: coping patterns in post head trauma patients, The International Journal of Clinical Neuropsychology 9 (1987), 145–148.

So in the case of denial, is it best to call-out your patient and confront them head-on with their deficits, or even more seriously, that they are in denial itself? Probably not. It is believed that patients who are confronted with this issue may experience more psychological distress. Instead, these patients are more likely to do better with psychological support and counseling outside of OT.^[6] Fleming , J.M. , and Ownsworth , T. (2006) . A review of awareness interventions in brain injury rehabilitation . Neuropsychol Rehabil , 16 , 474 – 500 .

So in essence, you have two clients in its simplest form for TBI and awareness. Both have a lack of awareness compared to baseline. The ones who will likely respond well to occupation-based intervention is the one without denial. In contrast, patients who respond with anger or resistance from the OTs feedback is likely to have less success for outcomes.^[7]Katz , N. , Fleming , J. , Keren , N. , Lightbody , S. , and Hartman-Maeir , A. (2002) . Unawareness and/or denial of disability: implications for occupational therapy intervention . Can J Occup Ther … Reference List

Outcome Measures

• Patient Competency Rating Scale (PCRS) ^[8]Noe, E., Ferri, J., Caballero, M. C., Villodre, R., Sanchez, A., & Chirivella, J. (2005). Self-awareness after acquired brain injury. Journal of neurology, 252(2), 168-175.
• Self-Awareness of Deficits Interview
• Assessment of Awareness of Disability
• Awareness Questionnaire^[9]van Heugten, C., Caldenhove, S., Crutsen, J., & Winkens, I. (2020). An overview of outcome measures used in neuropsychological rehabilitation research on adults with acquired brain injury. … Reference List

OT Intervention

So now that you are up to speed on these concepts and definitions, how do you go out providing rehab to patients with TBI and decreased metacognition?

You guessed it: the real-world practice of occupations. Examples include ADLs and IADLs. More specifically, examples include preparing a birthday gift, meal preparation, paying bills, scheduling a doctor’s appointment, or filling a pill organizer.^[10]Goverover, Y., Johnston, M. V., Toglia, J., & DeLuca, J. (2007). Treatment to improve self-awareness in persons with acquired brain injury. Brain Injury, 21(9), 913-923.

Does this mean that you should pick whatever interests you or you have available to provide as an intervention to your patient? No. OT practitioners should provide interventions that are holistic, client-centered, and meaningful to the client (values). They should be graded appropriately in difficulty and allow for breaks. Other factors include client contexts, the environment, extent of injury, family supports, mental health, and symptoms. A broader approach to overall health would likely help with the patient’s recovery such as sleep, diet, exercise, and leisure.

Good luck!