Self-Awareness Issues after Sustaining a Traumatic Brain Injury

By Kayela Robertson, M.S., and Maureen Schmitter-Edgecombe, Ph.D., Washington State University

 What is self-awareness?

Self-awareness is the ability to recognize changes in one’s cognitive abilities, such as memory and judgment that are important for completing everyday tasks.

What are self-awareness issues?

Difficulties with self-awareness are quite common, especially in the initial stages of recovery from traumatic brain injury (TBI). Self-awareness issues can result in decreased motivation to work on problem areas due to lack of recognition of the difficulties and compromised safety due to poor decisions or unrealistic goals.

What causes difficulties with self-awareness?

Research has shown that everyone has problems with self-awareness to some extent; we simply are not very good at estimating our own abilities. Self-awareness can worsen following TBI because of damage to structures in the brain that give us the ability to self-monitor. For example, based on prior experiences we can typically judge whether we will perform a task well or whether we will experience difficulties that may require using an organizational strategy (e.g., writing a reminder) or seeking assistance to complete the task. Persons with TBI can lose the ability to monitor their performance of such tasks, resulting in difficulty adjusting their idea of what they can and cannot do. Although damage to the brain is thought to be the main cause of self-awareness difficulties following TBI, emotional coping and adjustment are other issues that can also impact self-awareness.

Can difficulties with self-awareness be improved?

A neuropsychologist, speech therapist, occupational therapist, or other trained professional can facilitate self-awareness training. Inpatient and outpatient therapy have been shown to be helpful in improving self-awareness. It is important to keep in mind that self-awareness training is a slow process, and that the techniques provided may not work for individuals who have significant difficulty learning new information.

Common training techniques:

• Videotaping an individual while he or she performs a task. With the help of a clinician, the individual can then evaluate his or her own performance after the fact. The clinician can assist the individual in identifying difficulties that he or she is having and help develop compensatory strategies to use.
• Identifying the individual’s strengths and weaknesses. A clinician can help an individual connect how his or her strengths and weaknesses may impact performance of everyday tasks.
• Having a clinician give direct feedback about performance while the individual does a particular task. Often the individual will be asked to estimate how he or she will perform beforehand and then will be asked to re-evaluate his or her estimation once the task is finished.
• Treatment with a clinician aimed at improving mental health and reducing any emotional problems that may limit self-awareness.

How can caregivers help facilitate self-awareness?

• Be patient and do your best to understand that your loved one’s brain injury is causing difficulties with self-awareness; it’s not something that the individual can quickly change.
• Remind your loved one multiple times that he or she is not able to do something that they were able to do prior to injury. Do your best to give direct feedback, but remember that the brain injury makes it challenging for your loved one to understand their difficulties and they may not remember the difficulties moments later (especially if they have significant problems with memory).
• As your loved one recovers, you might be surprised at what he or she can do with a little guidance. Allow your loved one to be involved in safe activities as much as possible to build self-confidence. Encourage him or her to do things independently. When a mistake is likely or danger is possible, provide guidance to help correct behavior rather than completing the task for him or her.
• Demonstrate a task before your loved one attempts to complete the activity alone.
• Set realistic goals with your loved one and continually re-evaluate the goals as you see improvement. 
• Before completing a task, have your loved one estimate his or her performance. Provide your loved one with gentle corrective feedback as he or she does the task and talk about ways to improve performance in the future.

Things to keep in mind as a family member or caregiver of someone with a TBI:

• Healing takes time and often goes beyond just the initial year of recovery. Issues with self-awareness are usually worst in the beginning stages of recovery and tend to dissipate as the brain heals. Depending on the type and severity of injury, however, difficulties with self-awareness may be a long-lasting problem for some individuals.
• Learn to adjust to a “new normal.” When a family member sustains a TBI, a number of adjustments must be made within the family structure. If an individual experiences long-lasting impairments, it will take some time to fully understand these changes and how they impact the person with TBI and the family. Part of this is accepting the changes, grieving the loss of the person you once knew, and getting to know the person as he or she is now.
• Self-care is important to you and to your loved one’s recovery process. This is a stressful time for everyone involved, which can result in frustration and impatience. Be sure to take time for yourself.

Resources for caregivers:

1. Brain Injury Association of America
2. National Institute of Neurological Disorders and Stroke
3. Center of Excellence for Medical Multimedia – Online TBI Caregiver’s Program
4. Family Caregiver Alliance – Coping with Behavior Problems after Head Injury
5. Family Caregiver Alliance – Self-Care for Family Caregivers
6. Mayo Clinic – Free online book: Understanding Brain Injury for Families

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This article originally appeared in Volume 10, Issue 4 of THE Challenge! published in 2016.