Using occupation to facilitate self-awareness in people who have

acquired brain injury: A pilot study

doi:10.2182/cjot.05.0005

This paper was published in the CJOT Early Electronic Edition, May, 2005.

Jennifer M. Fleming

Sarah E. Lucas

Sue Lightbody

Key words

Self-awareness

Brain injury

Occupational therapy practice

Abstract
Background. Impaired self-awareness in people who have had an acquired brain injury (ABI) is a complex phenomenon that
impedes rehabilitation progress and outcome. Purpose.This pilot study investigated the effect of an occupation-based intervention program on the self-awareness and emotional status of people after ABI. Four male adults with impaired self-awareness
following ABI participated in this study.Each received a 10-week individualized program that focused on the performance of three
occupations for 1 to 2 hours per week. A facilitative approach was taken, using techniques to improve self-awareness described
in the literature. Repeated measures of participants' self-awareness and emotional status were taken pre- and post-intervention,
and analyzed descriptively. Results. Results indicated preliminary support for the effectiveness of the program in facilitating
participants' self-awareness. However, consideration of baseline and follow-up data indicated a complex picture. Increased
anxiety was found to accompany improvements in participants' self-awareness in all four cases. Practice Implications. This
study will assist occupational therapists with program development for clients who have had an acquired brain injury.

Rsum
Description. L'atteinte de la conscience de soi chez les personnes ayant subi un traumatisme crnien est un phnomne qui fait
obstacle la progression et aux rsultats de la radaptation. But. Cette tude pilote examinait l'effet d'un programme d'intervention fond sur l'occupation, sur la conscience de soi et sur l'tat motionnel des personnes ayant subi un traumatisme crnien.
Mthodologie. Quatre hommes d'ge adulte ayant subi une atteinte de la conscience de soi la suite d'un traumatisme crnien
ont particip cette tude. Chaque participant a suivi un programme individualis de 10 semaines, qui tait centr sur le
rendement dans la ralisation de trois occupations pendant une deux heures par semaine. partir d'une approche facilitatrice,
des techniques dcrites dans la littrature ont t utilises en vue d'amliorer la conscience de soi. Des mesures rptes de la
conscience de soi et de l'tat motionnel des participants ont t prises avant et aprs l'intervention. Ces mesures ont ensuite fait
l'objet d'une analyse descriptive. Rsultats. Les rsultats permettent de soutenir, de faon prliminaire, que le programme est
efficace pour rehausser la conscience de soi des participants. Cependant, l'analyse des donnes de base et des donnes de suivi a
rvl un tableau complexe. En effet, on a observ chez les quatre participants qu'une augmentation de l'anxit accompagnait
l'amlioration de la conscience de soi. Consquences pour la pratique. Cette tude peut tre utile aux ergothrapeutes qui
laborent des programmes d'intervention pour les clients ayant subi un traumatisme crnien.

major challenge faced by occupational therapists

working with clients with acquired brain injury (ABI)
is facilitating realistic self-awareness. Impaired selfawareness is a complex phenomenon, which is often
described by clinicians as the central obstruction to clients
achieving progress in rehabilitation and good outcomes
(Hart, Giovannetti, Montgomery, & Schwartz, 1998).
Research has shown that clients' lack of self-awareness is
associated with poor motivation for rehabilitation (Fleming,
Strong, & Ashton, 1998), limited progress (Hendryx, 1989),
and high strain on their relatives (Koskinen, 1998).
Conversely, accurate self-awareness in clients has been
associated with their increased participation (Fleming et al.,
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1998) and performance in rehabilitation (Lam, McMahon,

Priddy, & Gehred-Schultz, 1988), successful community and
vocational reintegration (Ezrachi, Ben-Yishay, Kay, Diller, &
Rattok, 1991; Sherer, Bergloff, et al., 1998; Trudel, Tyron, &
Purdum, 1998), and less strain on their relatives (Koskinen,
1998). Therefore, treatment of impaired self-awareness in
adults with ABI is considered to be important in the rehabilitation process. This paper describes a pilot study of an
occupational therapy intervention program for adults with
impaired self-awareness using single-case study data.

Literature review
Prigatano and Schacter (1991) highlighted the difficulty in
simply defining self-awareness, declaring it to be "the capac-

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ity to perceive the 'self ' in relatively 'objective' terms while
maintaining a sense of subjectivity" (p. 13). Individuals with
impaired self-awareness commonly experience difficulty
understanding the resulting impairments from their injury
and the impact these impairments have on their functional
ability (Fleming & Strong, 1995; Mateer, 1999; Sherer, Boake,
et al., 1998), as well as establishing realistic goals for the
future (Fleming & Strong, 1995). Clients' self-awareness is
poorer for activities that involve higher cognitive, social and
emotional function, compared to physical function and
activities of daily living (Fleming & Strong, 1999; Prigatano,
1996; Sherer, Boake, et al., 1998).
Although improvements in clients' self-awareness after
ABI are generally seen as positive for rehabilitation and outcome, they have been associated with increased emotional
distress (Fleming et al., 1998; Prigatano & Fordyce, 1986a;
Wallace & Bogner, 2000). Adults with more accurate selfawareness have been found to have higher levels of depression
(Fleming et al., 1998; Malec, Machulda, & Moessner, 1997)
and anxiety (Fleming et al., 1998), and lower satisfaction with
quality of life (Koskinen, 1998). Difficulty performing tasks
(Klonoff, O'Brien, Prigatano, Chiapello, & Cunningham,
1989), or failure when attempting to resume life roles
(Ownsworth & Oei, 1998) can leave individuals with ABI
vulnerable to depression and catastrophic reaction.
Psychological denial of disability as opposed to neurological
impairment of self-awareness (Giacino & Cicerone, 1998;
Malia, 1997; Prigatano & Klonoff, 1998) may also play a role
in precipitating emotional distress if a breakdown of protective mechanisms occurs when a client is confronted with
feedback in therapy (Giacino & Cicerone, 1998; Katz,
Fleming, Hartman-Maeir, Keren, & Lightbody, 2001). No
conclusive evidence exists supporting the use of differential
treatments for those with impaired self-awareness and denial
of disability (Sherer, Oden, Bergloff, Levin, & High, 1998).
However, it has been suggested that therapists need to
consider the interplay of neurological impairment and
psychological denial in an individual when deciding on treatment approaches (Katz et al., 2001; Malia, 1997; Prigatano,
1999). These research findings highlight the need for
therapists to be sensitive to emotional reactions, and implement highly supported and structured interventions
(Fleming & Strong, 1997; Klonoff et al., 1989).
Many recommendations have been made in the literature regarding treatment for impaired self-awareness. A key
theme is the importance of building a positive therapeutic
alliance with the client in order to effectively guide him or her
towards more realistic self-awareness (Barco, Crosson,
Bolesta, Werts, & Stout, 1991; Bieman-Copland & Dywan,
2000; Katz & Hartman-Maeir, 1998; Malia, 1997; Prigatano,
1999). Task selection should be based on the interests (Katz &
Hartman-Maeir, 1998) and goals of the client (Berquist &
Jacket, 1993; DeHope & Finegan, 1999), and emphasis should
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be placed on developing a client's strengths (Barco, et al.,

1991). The majority of specific intervention techniques
described in the literature address the three levels of awareness identified in Crosson et al.'s (1989) model. These are
intellectual awareness (understanding impairments), emergent awareness (recognising when impairments are affecting
performance), and anticipatory awareness (anticipating
when impairments will affect performance).
It is generally accepted that two approaches to cognitive
rehabilitation exist: restorative and compensatory (Barco et
al., 1991; Ben-Yishay & Diller, 1993; Cicerone et al., 2000;
Mazaux & Richer, 1998). Restorative or facilitatory techniques widely recommended in the literature for improving
clients' self-awareness include educating the client and family
(Barco et al., 1991; DeHope & Finegan, 1999; Katz &
Hartman-Maeir, 1998; Mateer, 1999; Sherer, Oden, et al.,
1998); planned failure where clients experience their impairments in real-life situations in conjunction with therapist
support (Barco et al., 1991; DeHope & Finegan, 1999; Mateer,
1999); specific, timely, and consistent therapist feedback
regarding clients' task performance (Barco et al., 1991;
DeHope & Finegan, 1999; Katz & Hartman-Maier, 1998;
Mateer, 1999); and videotaped feedback (Barco et al., 1991;
Mateer, 1999; Sherer, Oden, et al., 1998). Other faciliatory
techniques include client analysis of the underlying skills
required for task performance and prediction of performance (Katz & Hartman-Maier, 1998), comparison of client
and therapist ratings of task performance (Barco et al, 1991;
Cicerone, 1989), individual and group/family counselling
and psychotherapy (Andersson, Gundersen, & Finset, 1999;
Mateer, 1999; Prigatano, 1986; Sherer, Oden, et al., 1998),
cognitive retraining activities conducted in a holistic milieuoriented rehabilitation program (Prigatano & Fordyce,
1986b; Klonoff et al., 1989; Sherer, Oden, et al., 1998), and
collaborative formation of strength and weakness lists
(Klonoff et al., 1989; Barco et al., 1991). Compensatory
approaches for impaired intellectual, emergent and anticipatory awareness have been well described by Barco et al.
(1991), for use when facilitatory techniques fail.
Although these various treatment modalities have been
recommended based on clinical experience, little empirical
research has been conducted to validate their effectiveness.
Research has largely been of a case study nature, with a single
participant, or small numbers of participants. Several authors
have investigated the effects of group therapy programs for
improving clients' self-awareness with mixed results
(Ownsworth, McFarland, & Young, 2000; Ranseen, Bohaska,
& Schmitt, 1990; Youngjohn & Altman, 1989). The use of a
board-game format has been found to improve clients'
knowledge of their potential impairments (Zhou et al. 1996),
and understanding of their impairments (Chittum, Johnson,
Chittum, Guercio, & McMorrow, 1996). Prediction of performance followed by feedback has also been found to improve
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clients' knowledge of impairments (Rebmann & Hannon,
1995; Schacter, Glisky, & McGlynn 1990; Schlund, 1999).
Most of the self-awareness literature has been generated
by professions other than occupational therapy (eg. neuropsychology), however occupational therapy researchers
have more recently begun to contribute to the general body
of knowledge and take initial steps to empirically evaluate
treatment strategies. Occupational performance has been
viewed as a product of the contributions of the human
system, the task, and the environment (Kielhofner & Forsyth,
1997). The Model of Human Occupation suggests that occupations that are valuable and meaningful to the individual
should be chosen to facilitate his or her sense of efficacy
(Kielhofner & Forsyth, 1997). Katz and Hartman-Maeir
(1997, 1998) have emphasised the unique contribution that
occupational therapists can make in the treatment of
impaired self-awareness, by focusing on the individual's
occupational performance in the context of meaningful daily
tasks, where the effects of impairments can truly be observed.
Toglia (1998) proposed a model of cognitive rehabilitation, the dynamic interactional model, which incorporates
treatment for impaired self-awareness, but does not focus on
it explicitly. Within a multi-context treatment approach,
clients are trained to apply remedial and compensatory
strategies in the context of various tasks and environments to
facilitate the transfer of learning, and produce changes in
common behaviours. Specific strategies for improving
clients' awareness, such as self-prediction, self-monitoring
/self-evaluation, and role-reversal, can be incorporated in this
approach. The effectiveness of Toglia's (1998) multi-context
treatment approach and awareness training techniques,
combined with those recommended by Barco et al. (1991),
were evaluated by Landa-Gonzalez (2001) in relation to a
client with traumatic brain injury (TBI) 8 years post-injury,
with positive results.
In 2000, Toglia and Kirk proposed the dynamic comprehensive model of awareness, a model developed more specifically to guide intervention for impaired self-awareness.
Similar to the multi-context treatment approach, occupational performance is the basis of treatment. However, rather
than incorporating strategies to improve self-awareness into
cognitive rehabilitation, the specific focus of this model is on
improving the individual's sense of mastery and control
during occupational performance in order to improve his or
her self-awareness. Recommended treatment strategies
include the initial use of emotionally neutral tasks due to
clients' decreased ability to recognise errors in highly valued
tasks; setting the challenge appropriately to facilitate clients'
error recognition and correction; the use of techniques that
guide the client to discover his or her own errors as opposed
to verbal feedback from others; and giving clients feedback
using the sandwich format, where negative comments are
preceded and followed by positive feedback. The effectiveness
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of treatment strategies related to the dynamic comprehensive

model of awareness has yet to be empirically evaluated.
Further investigation regarding the effectiveness of intervention techniques described in the literature, particularly
those related to the facilitation of self-awareness in the
context of occupational performance, is warranted. The
facilitation techniques promoted in the literature, particularly
those based on occupational performance, have been used to
develop an occupational therapy approach to the treatment of
impaired self-awareness. The aim of this pilot study was to evaluate the effectiveness of an individualized occupation-based
approach for adults with ABI for facilitating self-awareness and
impacting on emotional status. Specific objectives were:
(1) To determine whether the participants' self-awareness
improved over the period of intervention;
(2) To determine if gains in self-awareness are maintained
at a 4- to 5- week follow-up;
(3) To investigate whether participation in the program
is associated with increased emotional distress (as a
result of improved self-awareness).

Method
Participants
Four participants were referred to the study from a specialist
community-based rehabilitation service for people with ABI.
Selection criteria for participants included being 15 to 65 years
of age, having a diagnosis of severe brain injury (traumatic or
acquired), being more than 12 months post-injury, having a
clinical presentation of impaired self-awareness, having an
available significant other, having no persistent cognitive
confusion or severe communication impairments, and not
being involved in other formal occupational therapy treatment programs. Participant demographic and diagnostic
information are presented in Table 1.

Measures
Two measures were utilised to evaluate changes in self-awareness
and two measures were used to evaluate emotional status as
listed below. A satisfaction survey that asked participants to
rate their perceptions of the program was also completed by
the participants on completion of the program.

1. Self-Awareness of Deficits Interview (SADI)

The SADI (Fleming, Strong, & Ashton, 1996) is an interviewerrated structured interview based on a model of self-awareness
proposed by Fleming and Strong (1995). The SADI consists of
three sections that allow collection of qualitative and quantitative data in relation to (a) clients' self-awareness of deficits, (b)
clients' self-awareness of functional consequences of deficits,
and, (c) clients' ability to set realistic goals for the future
(Fleming et al., 1996). Background knowledge of the client's
current level of functioning, which may require collection of
collateral information from significant others, is required for

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TABLE 1
Participant demographic and diagnostic information.
Participant
Variable

Age

32

23

37

40

Cause of ABI

Work-related fall

MVA (passenger)

Light plane crash

Subarachnoid
haemorrhage

Years since injury

2.5

4.5

Initial GCS

3/15

3/15

6/15

Length of PTA

60 days

90 days

80 days

Prior occupation

Plumber

University student
(architecture)

Unemployed, occasional
handy-man & skydiving
instructor

Self-employed glass
fitter/repairer

Significant other

Mother

Mother

Sister

Wife

Note. All participants were male. ABI = acquired brain injury; MVA = motor vehicle accident; GCS = Glasgow Coma Score; PTA = post traumatic amnesia.
Dash indicates data unavailable.

the interviewer to rate the responses on a 4 -point scale. Each

section is given a score ranging from 0 (no disorder of selfawareness) to 3 (severe disorder of self-awareness). The three
sections can be summed to give a maximum possible score of
9, with higher scores indicating more severe impairment of
self-awareness. The SADI has been found to be a useful
measure of client self-awareness in previous research
(Fleming et al., 1998). Two inter-rater reliability studies have
been conducted with acceptable ICC values of 0.82 (Fleming
et al., 1996) and 0.85 (Fleming et al., 1998). High test-retest
reliability has also been demonstrated (ICC = 0.94, Simmond
& Fleming, 2003). The SADI was able to discriminate
between subjects with traumatic brain injury (TBI) and
spinal cord injury (SCI), with results indicating that those
with TBI had generally greater impairment of self (Fleming,
Tooth, Connell, & Strong, 2002).

2. Patient Competency Rating Scale (PCRS)

The PCRS (Prigatano et al., 1986) assessment requires the
client and relative to independently rate the client's ability to
perform 30 behavioural items on a 5 -point Likert scale, with
each item given a rating from 1 (can't do) to 5 (can do with
ease). The perceived competency on all items can be summed
to produce a score out of 150. The discrepancy between client
and relative ratings can provide an impression of the level of
self-awareness. For the purpose of this study, the discrepancy
was calculated by subtracting the relative's score from the
participant's score to produce a difference score. Higher
difference scores represent more impaired self-awareness.
Numerous researchers (Fleming et al., 1998; Prigatano, 1996;
Wallace & Bogner, 2000) have operationalized self-awareness
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using the PCRS since its development. Prigatano, Altman,

and O'Brien (1990) found acceptable overall test-retest reliability for 17 clients (Pearson's r = .97) and their relatives
(Pearson's r = .92), and test-retest reliability (r significant at
p<.05) for 27 out of 30 items for clients and 28 out of 30 for
relatives. Fleming et al. (1998) found the PCRS to have
acceptable test-retest reliability over a 1-week period (ICC
value of .85; n = 20), and strong internal consistency for both
the client (Cronbach's alpha = .91; n = 55) and relative
versions (Cronbach's alpha = .93; n = 50). High inter-rater
reliability (average r = .92) has been found for staff ratings of
28 patients (Fordyce & Roueche, 1986).

3. Center for Epidemiologic Studies - Depression

Scale (CES-D)
The CES-D (Devins & Orme, 1985; Radloff, 1977) is a
20-item self-report questionnaire that assesses frequency and
duration of depressive symptomatology and positive affect in
the preceding week. The respondent rates the occurrence of
each feature on a scale of 0 (rarely or none of the time) to 3
(most or all of the time). Higher scores out of a maximum of
60 indicate greater distress. The CES-D was primarily
developed as a screening instrument for psychological
distress, as well as for research specifically within the
non-psychiatric population regarding the relationship
between depressive symptoms and other variables (Devins &
Orme, 1985). Relevant to ABI research, the CES-D's
decreased emphasis on somatic depressive symptoms reduces
the likelihood of reported distress being confounded by
medical conditions that may produce similar symptomatology
to depression (Devins & Orme, 1985). Radloff (1977) has
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proposed that scores over 16 may signify some form of
depression, while Barnes and Prosen (1984) suggested
evaluating scores using the categories of 0 to 15.5 (not
depressed), 16 to 20.5 (mild depression), 21 to 30.5 (moderate
depression), and 31 or more (severe depression). Test-retest
reliability studies on the CES-D have been characterised by
consistent results across various retesting intervals (Radloff,
1977). Cronbach's alpha levels ranging from .84 to .90 (Barnes
& Prosen, 1984; Radloff, 1977) indicate acceptable internal
consistency. Devins and Orme (1985) described a range
of studies that demonstrated the construct and convergent
validity of the CES-D.

4. Hospital Anxiety and Depression Scale (HADS)

The HADS (Zigmond & Snaith, 1983) was developed specifically for use with people in non-psychiatric hospitals, and consists of 14 questions, 7 of which relate to anxiety (HADS-A)
and 7 to depression (HADS-D). The HADS uses a 4-point
rating scale ranging from 0 to 3, with higher scores indicating
higher emotional distress. Like the CES-D, the HADS does
not include symptoms that may relate to both emotional and
physical disorders. A total score of 21 is possible for each
of the subscales. Zigmond and Snaith (1983) suggested a
scoring range of 7 or less (non-case of anxiety or depression),
8 to 10 (doubtful case of anxiety or depression), and 11 or
more (definite case of anxiety or depression). Internal
consistency ranged from .76 to .41 for the anxiety subscale
(p < .01) and .60 to .30 for the depression subscale (p < .02)
(Zigmond & Snaith, 1983). Significant spearman correlations
between the subscale scores and interviewer assigned ratings
for depression (0.70, p<.001) and anxiety (0 .74, p < .001)
suggested the scale is a valid measure of severity (Zigmond &
Snaith, 1983).

Procedures
The study was granted ethical clearance by The University of
Queensland's ethics committee and all participants provided
informed consent. Baseline, pre- and post-intervention, and
follow-up assessments were conducted to evaluate the
effectiveness of the program. Given time limitations, it was

not possible to collect both baseline and follow-up data for

all four participants. Participants 1 and 2 underwent preintervention assessments and then immediately commenced
on the program for 10 weeks, after which a post-intervention
assessment was conducted. These two participants were
followed up 4-5 weeks after they had finished the program, in
order to investigate maintenance of gains. Participants 3 and
4 were assessed 5 weeks prior to commencing the program
and then again immediately before commencing the
program to provide some baseline data. Participants 3 and 4
were reassessed upon completion of the program. The design
of the study resulted in all four participants having pre- and
post-intervention scores, and participants 1 and 2 also having
follow-up scores, and participants 3 and 4 also having baseline scores.
All assessments were conducted by the third author in
either a quiet room at the university or in the participant's
home. The participants' relatives completed the corresponding
versions of assessments where appropriate. Using the
interview transcripts, the SADI scores were assigned by the
first author, who was not involved in the delivery of the
intervention program, and was blind to which stage participants were at, at the time of assessment.
The 10-week program drew upon a multi-contextual
approach based on the Dynamic Interactional Model (Toglia,
1998) and had five key elements. These included developing
a therapeutic relationship, selecting and performing
meaningful occupations, gaining knowledge through
experience, self-monitoring, and using multiple feedback
techniques. Three participants attended all 10 sessions.
Participant 1 attended the first six sessions and did not attend
the last four sessions, but did return for the post-intervention
and follow-up assessments.
The program involved a highly structured and standardised format for each client. Collaborative goal setting was
used to select three occupations that the individualizedprogram would focus on. The targeted occupations were
those that the participant had impaired self-awareness for
according to his significant other, which were familiar and

TABLE 2
Occupations selected in collaboration with participants.

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Participant 1

Participant 2

Participant 3

Participant 4

Writing a job application

Preparing a hot meal safely

Cooking an affordable
meal one-handed

Budgeting

Drawing bathroom plans

on a computer

Using a diary and computer to

compensate for memory
problems

Saving money to join a

gym

Using a whiteboard and memory

strategies to complete daily
routine

Budgeting

Drawing computer-assisted
designs

Learning to play lawn

bowling

Performing housework duties

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TABLE 3

TABLE 4

Self-Awareness of Deficits Interview (SADI) scores.

Patient Competency Rating Scale (PCRS) scores.

Participant

Participant

Baseline

PrePostFollowintervention intervention up

Note. Scores range from 0-9. Higher scores represent greater impairment of selfawareness.

meaningful for the participant. The occupations selected by

the 4 participants are outlined in Table 2. The intervention
program was implemented in the home, community, and at
the university as appropriate for the particular occupation
being addressed, with sessions lasting for 1 to 2 hours per
week. The therapist offered a high level of support throughout the program, endeavouring to provide a non-threatening
environment and build positive therapeutic alliances.
Intervention techniques suggested in the literature to
improve self-awareness were used, including participant
analysis of underlying skills, self-prediction and selfevaluation through pre- and post-occupation evaluation
forms. Other techniques used were setting the just right
challenge, supported and structured real-life occupational
performance, brain injury education, timely non-confrontive
verbal feedback delivered in the sandwich format, and videotape feedback.

Results
Self-awareness
Given the case-study nature of this investigation, descriptive
statistics were used to analyze the data. SADI scores, where
higher scores represent greater impairment of self-awareness,
decreased in all participants over the pre- to postintervention period. However, interpretation of the data
becomes complicated when baseline and follow-up scores are
examined (see Table 3). At follow-up participant 1's score
rose again, while participant 2's score fell further. While
participant 3's baseline score was maintained at preintervention, participant 4's increased.
PCRS difference scores were calculated by subtracting
the relative's ratings from the participants' self-ratings to give
an indication of level of self-awareness, where higher scores
indicate more impaired self-awareness. As seen in Table 4, the
PCRS difference scores decreased for three of the participants
over the intervention period. Post-intervention and follow-up
difference scores were unable to be obtained for participant 2,
whose significant other did not complete the corresponding
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Base- Preline
intervention

PostFollowintervention up

1
Self-rating
Relative-rating
Difference score

130
92
38

123
107
16

128
91
37

2
Self-rating
Relative-rating
Difference score

108
101
7

128
-

141
-

3
Self-rating
Relative-rating
Difference score

118
99
19

122
100
22

124
113
11

4
Self-rating
Relative-rating
Difference score

141
101
40

145
97
48

139
104
35

Note. Higher ratings represent greater perceived competency. Difference

score = participant self-rating minus relative-rating. Dashes indicate missing data.

line and follow-up scores complicated the interpretation

of the results. Participant 1's difference score increased at
follow-up by almost the same amount that it fell over the
intervention period. Both participant 3 and 4's difference
scores rose between baseline and pre-intervention.

Emotional distress
Emotional distress results, as measured by the CES-D and
HADS-A and D, are presented in Table 6. An increase in
depressive symptoms was found over the intervention period
for three out of four participants on the CES-D, and two out of
four participants on the HADS-D. Anxiety symptomatology
increased over the intervention period for all four participants
on the HADS-A. Individual patterns of emotional
distress were variable. Although participant 1 and 2 both
showed slight increases in anxiety and depression during the
intervention period, participant 1 showed a marked increase at
follow-up, while participant 2 returned to below preintervention levels at follow-up. Participants 3 and 4
displayed only slight fluctuations in depression and anxiety
over the baseline and intervention periods.

Satisfaction survey
Satisfaction survey results are presented in Table 5. Results
were mixed, with some participants indicating more positive
responses than others. Subjective comments made in
response to requests for feedback from the therapist are documented in the case studies below.
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TABLE 5

TABLE 6

Emotional distress scores on the Center for Epidemiologic

Studies Depression Scale (CES-D), Hospital Anxiety and
Depression Scale (HADS - A and D).

Participant satisfaction ratings of the program.

Participant

Baseline

CES-D
1
2
3
4
HADS - D
1
2
3
4
3
HADS - A
1
2
3
4

Preintervention

PostFollowintervention up

15
30
18
3

29
14

17
0

3
27
19
0

3
15
6
1

4
7

6
2

2
11
8
1

9
2

7
10
6
0

8
14
10
4

11
8

Case studies
Participant 1:
At the time of referral to the study, participant 1 was living
independently in the community with support from several
brain injury groups providing case management and
attendant care. He was independent in personal care and
instrumental activities of daily living with the exception of
budgeting, and regularly sought financial assistance from
family and community groups. He was receiving a Disability
Support Pension and had a history of multiple failures at
attempting to secure work. On initial assessment he demonstrated a severe impairment of self-awareness (SADI score =
9). During the first six sessions of the program, Participant 1
accomplished his first two occupational goals. Despite his
verbal expression of enthusiasm for the program, it was difficult to engage him in these chosen activities as he continually
found excuses not to participate, and his responses to feedback (e.g. about the inappropriate content of his letter of job
application) were defensive. He refused to engage in any
activities relating to his third goal, budgeting, and did not
attend the final four sessions of the program, however his
satisfaction ratings indicated he enjoyed the program and felt
he benefited a small amount from it.
Participant 2:
The second participant had recently moved to live alone in a
flat, and was contemplating returning to University to
continue his studies. He was independent in his personal
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Enjoyment of program
Relevance of goals
Involvement in goal setting
Achievement of goals
Benefited from program
Benefit of therapy at
university
Benefit of therapy in
home/community
Readiness to finish
program

4
3
1
3
2
2

4
4
4
4
4

3
2
1
3
3
2

3
3
2
3
3
2

Note. Participants rated each question at the post-intervention stage on a 4-point

scale ranging from: 1 (not at all), 2 (a little), 3 (a fair bit), and 4 (a lot). Dash indicates data unavailable.

Note. Higher scores represent greater levels of depression and anxiety.

50

Participant
Questions

ADL, but reported some difficulties with aspects of instrumental ADL such as meal preparation. He had limited
contact with his family and little other social support. He was
seeing a psychiatrist and taking antidepressants. During
participation in the occupations, participant 2 was very
reluctant to rate his own performance using a rating scale,
but found discussing videotaped feedback useful. For example, after viewing the video of his first cooking performance
he said, "You're the best sore thumb I've ever had. The video
really showed me what was happening." At times he
despaired about his repeated difficulty with tasks he found
easy before the injury, but his responses were generally positive. For example: "The drawing exercise I loved doing. I'm so
grateful for that exercise which has opened up my past and
helped me so much. I'm getting an idea of what I am capable
of. My eyes are getting opened" and " I enjoyed the program
a lot. I received lots of feedback. The thing I liked most about
the program was that it wasn't stock standard. I loved the
planning and the way things happened from there."
Participant 3:
Participant 3 was living in shared accommodation within the
community and had strong relationships with family members who provided regular support. He was independently
mobile but had a hemiplegia. He was independent in his
personal ADL (activities of daily living) but struggled with
instrumental ADL, particularly managing finances, preparing
meals and other domestic duties. The initial SADI indicated
he had some awareness of his disabilities and tended to focus
on his physical disabilities. There were many other deficits
described by his significant other that he did not acknowledge, including behavioural and cognitive changes. He also
exhibited mild depression on screening assessment. During

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the program he appeared to enjoy discussing his performance with the therapist and examining discrepancies
between previous, perceived and actual performance of
occupations. Yet, when asked to rate his performance on the
self-rating scales he said, "This is baby stuff. I don't like this.
You have a head injury and you get treated like a baby." At the
conclusion of the program, he had made some personal
gains, including improved safety techniques in one-handed
cooking, using money management techniques to save the
membership fee for the gym, and increased socialization
through attending the bowls club. The SADI indicated that he
had improved self-awareness of his limitations, but still had
difficulty in setting realistic goals for the future. When asked
what was gained from the program he said, "Having to use
my calendar to know when my appointments with you were
each week. I had to work on being punctual."
Participant 4:
The fourth participant lived at home with his wife and two
young children. He was walking unaided, and was independent in his personal ADL, but required assistance with instrumental ADL. He had little physical deficits but significant
impairment of executive functions. Self-awareness assessments indicated that he had little awareness of any deficits
other than a general understanding that "the hole in my head
is stopping me from working. He was not depressed or
anxious. He had great difficulty identifying setting goals and
was reluctant to participate in any occupations that did not
relate to his unrealistic goal of returning to work. He often
said, "I can't see the point of it!"
Despite his reluctance he could be coaxed to engage in
each key occupation and supporting purposeful activities.
Although he was very reluctant to use self-rating scales or to
comment on his occupational performance, he listened
keenly as questions were asked by his significant other
relating to his performance. He rated the program as fairly
enjoyable and stated that the most beneficial element was
"Inside information the feedback I'm getting from you."
He also reported that he felt that he had benefited from his
involvement in the program, that the goals were relevant and
that he had achieved the goals quite well.

Discussion
This study investigated the effect of an occupation-based
intervention on the level of self-awareness and emotional
status of four participants with ABI who were independent in
personal ADL but had difficulties with instrumental ADL,
social and vocational activities. The unique focus of the
program was the use of meaningful occupations to provide
the individuals with experiential feedback of their current
level of ability through the use of self-monitoring and
supportive therapist feedback within the context of a
therapeutic relationship. Comparison of data from objective
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pre- and post-intervention assessments gives some preliminary support for the use of occupation in facilitating clients'
self-awareness. However, this is complicated when consideration is given to the varied baseline and follow-up results, and
the participants' mixed responses to the program.
The first objective of the study was to determine whether
the participants' self-awareness improved over the period of
intervention. Modest improvements in self-awareness over
the intervention period were observed for all participants.
The second objective was to determine if gains in selfawareness were maintained at a 4-to-5 week follow-up.
Follow-up data was obtained for two participants. One
participant did not maintain the gains in self-awareness seen
over the intervention period, but the other furthered these
gains at follow-up. The third objective was to investigate the
effect of the program on the participants' level of emotional
distress. Emotional responses were variable amongst participants. Slight increases in anxiety symptoms were found
among all four participants and slight increases in depressive
symptoms were found for three of the participants.
Interpretation of the results requires analysis of each case
individually, due to the heterogeneity of the ABI population
(Doig, Fleming, & Tooth, 2001). Although participant 1
demonstrated gains in awareness over the intervention period,
these gains were not maintained at a 4-week follow-up. PCRS
scores indicated that gains in awareness over the intervention
period were accompanied by functional gains, which were
also not maintained at follow-up. Results indicated that
emotional distress developed over the intervention period,
and escalated at follow-up. Participant 1 presented with a
severe disorder of self-awareness, with signs of denial of
disability. The increase in participant 1's emotional distress
may have been associated with a breakdown of the protective
mechanisms associated with denial, when feedback was given
during the program (Giacino & Cicerone, 1998; Katz et al.,
2001). Negative responses to feedback from the therapist and
avoidance techniques were observed during the program,
providing support for suggestions that the contribution of
psychological and neurological unawareness should be considered when selecting treatment approaches (Katz et al.,
2001; Malia, 1997; Prigatano, 1999).
Bieman-Copland and Dywan (2000) argued that the use
of confrontational strategies, such as giving direct feedback,
serve to entrench confabulatory beliefs, and recommended
an alternative behavioural therapy approach. They argue that
such an approach involves therapists working collaboratively
with clients, without directly confronting them about their
brain injury, in order to reduce targeted inappropriate behaviours. This kind of approach, or a more traditional psychotherapeutic approach, may be more beneficial than an
occupation-based intervention program in improving the
self-awareness of clients who display high levels of denial of
disability. This case (i.e. participant 1) and the issue of denial
1

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versus unawareness, including implications for occupational
therapy intervention, have been more fully discussed elsewhere (Katz et al., 2001).
Participant 2's SADI scores demonstrated improvements
in awareness over the intervention period, and further gains
at follow-up. PCRS self-ratings suggested that functional
gains were made throughout the program, and also increased
at follow-up. The PCRS relative's ratings were unavailable to
verify this pattern of awareness and functional improvement.
Whilst these results may suggest that improvements in awareness and functional ability were due to resolution of neurological impairment over time, therapist observations and
verbal and written feedback from the participant indicated
that this may have been the result of a sustained therapeutic
effect from the program. It is possible that he continued to
use the self-monitoring/self-evaluation techniques learnt
during the program after the program ceased, resulting in
further gains in self-awareness and functional ability.
Feedback from participant 2 indicated that the development
of emotional distress over the intervention period was associated with difficulty performing tasks when attempting to
resume former roles. This is consistent with suggestions in
the literature (Klonoff, O'Brien, Prigatano, Chiapello, &
Cunningham, 1989; Ownsworth & Oei, 1998).
Fairly consistent SADI and PCRS difference scores prior
to commencing the program, and a decrease at postintervention indicated that participant 3 made gains in
awareness over the intervention period. Functional gains
were noted over the intervention period by both the therapist
and the relative, whose PCRS rating increased postintervention. Considering these functional gains, the consistency of the participant's functional self-ratings at all stages is
likely to be due to decreased self-awareness before the
program, and more accurate awareness at post-intervention.
Participant 3 displayed slight fluctuations in emotional
distress during the base-line and intervention period in a
complicated pattern. Follow-up scores would have been
beneficial in determining maintenance of gains, and may
have shed more light on the pattern of emotional distress.
SADI and PCRS difference scores indicated that participant 4's self-awareness and functional ability improved over
the intervention period, although these scores deteriorated
between baseline and pre-intervention. Follow-up scores may
have been useful to further investigate this fluctuating pattern
of awareness. Although emotional status data indicated that
participant 4 was not depressed or anxious at any stage,
improvements in his self-awareness were accompanied by a
slight increase in emotional distress on one of the two
depression scales, and the anxiety scale.
The results demonstrate a link between improvements in
self-awareness and some form of increased emotional distress in
all participants. This confirms the importance of monitoring
emotional status when intervening to improve self-awareness.
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It also suggests that therapists may need to act cautiously and

evaluate the potential outcomes of improving individual
client's self-awareness in terms of whether the benefits
outweigh the costs. Considering participant 1's emotional
reaction to the program, this may especially be the case if a
client displays more psychological denial of disability than
neurological unawareness.
Examination of the subjective satisfaction survey results
indicated that responses were generally positive in terms of
the participants' enjoyment and perceived benefit of the
program, and the perceived relevance and achievement of the
goals. Less positive responses were received regarding the
participants' level of involvement in goal setting and their
readiness to finish the program after 10 weeks. Although
particular attention was paid to selecting meaningful occupations that reflected participants' goals, this is an area that
may require further emphasis in future intervention studies.
Perceptions of unreadiness to finish the program highlight
the need for the therapist to concentrate on debriefing the
client, and evaluate gains made. Achieving a sense of closure
of the therapeutic relationship towards the end of the program
is essential, as well as assuring the participant of adequate
follow-up through other agencies if required.
Self-monitoring is recognized as an important technique
to help an individual identify and to gain an element of
control (Katz & Hartman-Maeir, 1998, Toglia & Kirk, 2000).
In this program we used a formal self-rating scale to facilitate
self-monitoring and found that all four participants were
reluctant to assign a ratings to their perceived skill level. Less
formal methods of self-monitoring such as viewing videotapes of performance were better accepted and valued by
participants. This highlights the importance of facilitating
self-monitoring using methods that are non-confrontational
and respect the individual's desired level of self-disclosure to
the therapist.
The use of the SADI in this study was beneficial both to
document objective changes in self-awareness, and to gain
general information regarding the participants' awareness,
which was used for treatment planning purposes and goal
setting. Although the PCRS is one of the few psychometrically investigated measures of self-awareness (Sherer,
Bergloff, et al., 1998), there are limitations in using it as a
measure of self-awareness. These include the potential bias in
relatives' ratings of the client's abilities (Fleming et al., 1996;
Prigatano, 1996; Sherer, Boake, et al., 1998), and the reliance
of the difference scores from two different sources (i.e. participants and relatives) who may have different interpretations of
the PCRS items. Possible distortion of test scores is also a limiting factor, when a treatment program aiming to improve the
client's self-awareness by addressing occupational performance
may also facilitate gains in functional ability.
Other limitations of this study include the design, which
did not allow for assessment of all participants at every stage

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due to the time-frame; the small number of participants; and
the absence of a control group. However, because research in
this area is still in its infancy, the length and cost of delivering
intervention programs makes larger scale studies difficult.
Due to the present program being clinically realistic in the
nature of hours and staffing, the modest results suggest that
a program of this intensity is the minimum required to
improve self-awareness. With more hours per week and a
longer intervention period, gains could possibly be sustained
to a greater extent at follow-up. Future research should investigate the effects of a more controlled program, with larger
numbers of participants. Links between the intensity of the
program and level of improvement in clients' awareness
could also be examined, along with psychosocial outcomes
associated with improved awareness. In-depth qualitative
studies of clients' responses to programs may be beneficial in
identifying the most appropriate techniques for improving
self-awareness, and investigating the relationship between
improved self-awareness and emotional distress.
This study has provided preliminary support for the use
of individualised occupational therapy programs in facilitating self-awareness. The importance of occupational therapists investigating this topic further is stated well by Katz and
Hartman-Maeir (1997): "Occupational performance is the
core concept and focus of our profession, but awareness of
strengths and deficits, and executive functions are prerequisites for successful functioning in any occupation, task or
activity" (p. 61). This study suggests that while self-awareness
may be a pre-requisite for occupational performance, occupational performance may also be important in facilitating
the self-awareness of people with ABI.

Acknowledgements
This study was conducted with the assistance of a research
grant from The University of Queensland New Staff Research
Start-Up Fund to J. Fleming. The authors would like to
express their sincere gratitude to the four participants in the
study and their family members.

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Authors
Jennifer M. Fleming, PhD, BOccThy (Hons) is a Senior Research
Fellow of Occupational Therapy, School of Health and
Rehabilitation Sciences, The University of Queensland,
Brisbane, QLD, Australia, 4072. Email: j.fleming@uq.edu.au
Sarah E. Lucas, BOccThy (Hons) was an honours student at the
time of writing., School of Health and Rehabilitation Sciences,
The University of Queensland, Brisbane, and is presently an
Occupational Therapist, Occupational Therapy Department,
Gold Coast Hospital, Gold Coast Health Service District,
Queensland, Australia.
Sue Lightbody, BOccThy is a Research Assistant, School of Health
and Rehabilitation Sciences, The University of Queensland,
Brisbane, Australia.

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CAOT PUBLICATIONS ACE

VOLUME

73

NUMBER

CANADIAN JOURNAL OF OCCUPATIONAL THERAPY

FEBRUARY

2006

55