IMPORTANT! To complete Quiz 3, you'll need module 4 too!
All the information needed of module 3 to complete quiz 3 of the course 'Neuropsychological Rehabilitation' at Tilburg University.
This summary contains all the articles and book chapters, and also the most important information mentio...
MODULE 3: INTERVENTIONS FOR DEFICITS IN
AWARENESS AND FATIGUE
FLEMMING & ONSWORTH (2006)
o It has emerged that unawareness is not a unitary or an ‘all or nothing’ construct and
that awareness is a complex construct incorporating neural and cognitive processes,
as well as psychological factors.
o Awareness, or self-awareness, is defined as ‘the capacity to perceive the ‘self’ in
relatively ‘objective’ terms while maintaining a sense of subjectivity’.
o A disorder of self-awareness refers to a person’s ‘inability to recognise deficits or
problem circumstances caused by neurological injury’.
Overview of Awareness Interventions
Prigatano et al. (1982 & 1986)
o Described a holistic-oriented programme which involves a combination of cognitive
retraining and psychotherapeutic intervention and addresses affective issues as an
integral component of the programme.
o They recognised disturbances of self-awareness as a ‘substantial barrier to successful
rehabilitation outcome’.
o They demonstrated that patients who successfully completed the programme rated
their level of self-awareness as similar to staff ratings, whereas those who ‘failed’ the
programme universally overestimated their level of self-awareness compared to staff
ratings.
These findings not only illustrate the role played by self-awareness in
rehabilitation outcome, but also suggest that some people with disorders of
self-awareness may not respond to this treatment approach.
Klonoff et al. (1989)
o The cognitive retraining hour involved client working alongside each other on
cognitive retraining activities, receiving well-timed therapist feedback and being
involved in keeping records, timing tasks, graphing their own performance, and
writing strength and weakness lists.
The supportive group context and strong working alliance with the therapist
were seen as important in addressing emotional responses as they arose.
Fordyce & Roueche (1986)
o They identified a group of clients who originally underestimated their impairments as
compared with staff and relatives’ reports.
One subgroup of these clients displayed improved awareness in their self-
reports over the course of the programme, whereas the self-reports of another
subgroup showed increased discrepancy from staff and relative’s ratings and
an increase in emotional distress over the programme.
These results reinforced previous findings that not all individuals
benefit from interventions to enhance awareness and that increased
awareness can be associated with emotional distress.
,Module 3 A.E.M. van Wordragen 2100382
Sherer et al (1998)
o They described a comprehensive community re-integration rehabilitation programme
based on the assumption that increasing self-awareness facilitates the achievement of
better community re-integration in clients with brain injury.
o They used techniques to increase the awareness using family interventions, peer
feedback, education, roleplay etc.
There were no pre- and post-intervention measures of awareness described.
Side notes
o Most of the above programmes are based on a theoretical approach that recognises
the contribution of both neuropsychological and psychological elements to disorders
of awareness.
o Prigatano & Klonoff distinguished between unawareness that has neuropsychological
origin, which was termed ‘impaired self-awareness’ and unawareness with
psychological origin, named ‘denial of disability’, but it was later suggested that
this model be reconceptualises as four syndromes of unawareness determined by
lesion site.
Prigatano proposed that these syndromes will be ‘complete’ in clients with
bilateral brain impairment, who are likely to be unmotivated, passive but
non-resistant participants in rehabilitation.
In contrast, following unilateral brain impairment, these syndromes may be
‘partial’ and client are likely to demonstrate different methods of coping,
including non-defensive and defensive methods, and hence respond better to
different types of intervention.
Clients with non-defensive reactions are using premorbid ways of
coping that may no longer be effective, and with rehabilitation will
realise that heir impairments are preventing them from performing
activities unsuccessfully.
Clients with defensive coping styles may employ denial and projection,
show resistance to therapy, and accuse therapists of obstructing them
from achieving their goals.
The group with non-defensive coping would respond best to the
milieu-orientated neuropsychological rehabilitation
programmes, while those with defensive coping methods might
benefit more from individual psychotherapy approaches.
Psychotherapeutic treatment
o Psychotherapy is used to assist client to explore the meaning of their losses and
impairments and to re-establish a sense of meaning in their lives and form realistic
goals.
Langer & Padrone (1992)
o They proposed a tripartite model of awareness which integrates psychological
(motivational) factors with the neuropsychological/cognitive factors underlying self-
awareness by proposing three sources of individuals ‘not knowing’ their injury-related
deficits.
1. Not having the information due to a lack of assess to or inability to understand the
problem which manifests as unawareness in the individual client.
This can be addressed in rehabilitation by proving information and
feedback about deficits to the client.
, Module 3 A.E.M. van Wordragen 2100382
2. A neuropsychological problem with gleaning the implication of information so the
problem is minimised.
The clinician needs to work with the client to build structures to help
support the processing of information and use repetition to facilitate
learning.
3. The client denies or minimises information that is too painful for him or her to
deal with at a conscious level.
Awareness interventions need to be preceded or accompanied by efforts to
strengthen the client’s ego functions to support the knowledge.
o Such awareness issues should be dealt with early in the acute phase of rehabilitation,
using group and individual psychotherapy.
The clients need to be continually monitored to control for
neuropsychological and emotional distress.
Interventions based on the Pyramid model of awareness
o The pyramid model conceptualises awareness on three levels (in hierarchical
order):
1. Intellectual awareness: a basic knowledge of one’s brain injury deficits and their
implications.
2. Emergent awareness: the person’s ability to recognise a problem while it is
happening.
3. Anticipatory awareness: the ability to predict that a problem may occur.
o The pyramid model can be used to treat denial to indicate where the person’s ability
lies.
Barco et al. (1991)
o To facilitate intellectual awareness, it is recommended to educate client and family
about brain injury deficits, proving consistent feedback during therapy, videotaped
feedback, strength-and-weakness lists, and ‘planned failure’ lists.
o To facilitate emergent awareness the use of providing feedback during and after task
performance including videotaped feedback and comparison of self-ratings is advised.
o To facilitate anticipatory awareness they suggested assisting the client to plan and
anticipate problems prior to task performance in variety of situations.
Crosson et al. (1989)
o The client may also be taught a compensation technique appropriate to his or her
level of awareness:
Clients with intact anticipatory awareness can employ anticipatory
compensation: plan ahead to employ a compensatory strategy in situations
here a problem is anticipated.
Client who lack intellectual awareness require external compensation:
cueing or environmental mediation initiated by another person in the
client’s support system.
DeHope & Finegan (1999); Dattilo (1994); Willer & Corrigan (1994)
o They reported a self-determination approach to enhance self-awareness and
social functioning based upon the pyramid model combined with the leisure
education model.
The intervention consisted of three stages: education, practice in safe and
structured setting, and real-life consequences.
o Gains were attributed to improve self-awareness and self-monitoring.
None of the individuals progressed to achieve full anticipatory awareness.
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