ARTICLES

Reconstruction of
Identity After Brain Injury
Mark Ylvisaker
College of Saint Rose, Albany, USA

Timothy Feeney
Wildwood Institute, Schenectady, USA

ollowing severe traumatic brain injury, difficulty with behavioural adjustment

F and community reintegration is common. A potential contributor to this diffi-
culty is a sense of personal identity that is inconsistent with the restrictions on
activity and need for effortful compensation imposed by persistent impairment.
We summarise an information processing framework within which the impact of
schematic mental models of self is explained and present intervention proce-
dures designed to help individuals with traumatic brain injury reconstruct an
organised and positive sense of personal identity. We conclude the paper with
three instructive case illustrations.

“That’s who I am; that’s what am; right
or wrong, I can’t change that!”
At a pivotal moment in the mobster movie Carlito’s
Way, the hero utters these lines to the woman he
loves. They both know that he has recently chosen
a course of action that will result in personal disas-
ter. And they both know that the person Carlito
plans to help deserves nothing. But because Carlito
believes that he has a debt to pay and because he
has deeply implanted in his sense of self the con-
viction that important debts must be repaid, he
chooses self-destruction over life and love.
Our goal in this paper is to describe an infor-
mation processing theory within which apparently
irrational and self-destructive choices of this sort
can be readily understood, and to apply this theory
to the rehabilitation of young adults with traumatic
brain injury (TBI) who have behavioural difficul-
ties associated with their community reintegration.
In contrast to the fatalism implicit in Carlito’s dec-
laration, “I can’t change that,” our view is that
action-guiding schematic mental models of self
can change, and that rehabilitation professionals
have the opportunity to collaborate with the indi-
viduals they serve in constructing organised, posi-
tive, and personally appealing identities as life
unfolds after a serious brain injury.
The Population
Many young people with TBI enjoy a surprisingly
successful return to social, educational, and voca-
tional pursuits after their injury, with or sometimes
without intensive rehabilitation. The subpopula-
tion selected for special attention in this paper
includes adolescents and young adults with TBI
who experience substantial difficulty with commu-
nity reintegration after their injury and early reha-
bilitation. In many cases, their difficulty with
self-regulation after the injury is a complex conse-
quence of preinjury academic, vocational, social,
or behavioural problems, combined with direct
cognitive and self-regulatory effects of the injury
and with postinjury adjustment problems. When
the injury includes damage to the frontal lobes,
which are especially vulnerable in TBI (Adams et
al., 1980; Levin et al., 1991; Mendelsohn et al.,
1992), the resulting impairment of executive func-
tions may exaggerate problems with behavioural
and cognitive self-regulation that predated the
injury. Self-regulatory disturbance after TBI, par-

Address for correspondence: Mark Ylvisaker, Ph.D., 1171 Van Antwerp Rd. Schenectady, NY 12309, USA. Email:
ylvisakm@mail.strose.edu

BRAIN IMPAIRMENT
12 VOLUME 1 NUMBER 1 MAY 2000 pp. 12–28

ticularly in the presence of ventral prefrontal
damage (Levine, 1999; Levine et al., 1999), has
been shown to be more common than in carefully
matched controls from the same socioeconomic
cohort (Dikman et al., 1995). The resulting mix of
challenges for this group threatens to spiral out of
control in the absence of effective intervention and
ongoing support.
For several years we have served young adults
with TBI through a community support project
funded by the New York State Department of
Health. Individuals referred to the project must
present evidence of ineffective community reinte-
gration associated in part with behavioural con-
cerns. In addition, a majority of the people we
serve have a pre- and/or postinjury history of alco-
hol or drug abuse. Over the first four years of this
project, we served 325 young adults either directly
or indirectly by working collaboratively with their
service providers, employers, family members,
or others. The total estimated cost to the state for
these 325 individuals during the year before their
referral to the program exceeded $30,000,000US.
This figure includes medical, rehabilitation, and
correctional costs, but does not include lost pro-
ductivity, lost taxes, lost productivity of family
caregivers, and enormous stress for family and
service providers. Multiplied by the roughly four
decades of additional expected life for the mem-
bers of this group, the projected financial burden
is staggering if they are not effectively rehabili-
tated and supported.
This population has been neglected in most
published reports of TBI rehabilitation research,
because exclusionary criteria used in these stud-
ies typically include history of substance abuse,
psychiatric diagnosis, or significant behaviour
problems. This relative neglect of the group, com-
bined with their economic and social importance,
justifies increased attention in the rehabilitation
literature. However, the intervention themes
described in this paper also apply to less complex
and behaviourally troubling situations, a point to
which we return later.
A Framework for Person-
Centred, Context-Sensitive
Intervention and Support
Ylvisaker and Feeney (1998) described and illus-
trated a comprehensive approach to rehabilitation
for individuals with combined cognitive, behav-
ioural, communication, and executive system
impairment associated with TBI, or more specifi-
cally with frontolimbic injury. The approach has
a number of theoretical supports:
RECONSTRUCTION OF IDENTITY AFTER BRAIN INJURY
• theories of frontal lobe function from cogni-
tive, social, and general executive system per-
spectives (Grafman, 1995; Grafman at al.,
1993; Shallice, 1982, 1988; Shallice &
Burgess, 1991; Stuss & Benson, 1986)
• neuropsychological theories of the self and
consciousness (Damasio, 1999; Stuss,
1991a,b; Stuss & Alexander, 1999, in press;
Stuss et al., in press)
• Damasio’s work on somatic markers and the
inefficiency of learning from consequences fol-
lowing ventral frontal lobe injury (Bechera et
al., 1994; Bechera et al., 1996; Damasio, 1994)
• Barnard and Teasdale’s Interacting Cognitive
Subsystems approach to information process-
ing and psychotherapy (Teasdale & Barnard,
1993)
• Lakoff and Johnson’s analysis of abstract lan-
guage as metaphorical, including the lan-
guage used to construct a sense of self
(Lakoff & Johnson, 1980, 1999)
• Anderson’s findings regarding the severe lim-
itations on transfer of cognitive skill in normal
cognition (Singley & Anderson, 1989)
• associated theories of transfer in behavioural
psychology (Baer, 1981)
• Carr’s work on antecedent-focused behav-
ioural intervention (Carr et al., 1998)
• the extensive experimental work of Deci and
Ryan on self-motivation and the dangers of
over-reliance on extrinsic motivation (Deci,
1995)
• Vygotsky’s theories of cognitive development
and the associated apprenticeship approach to
teaching (Vygotsky, 1962, 1978)
• Mann’s exhaustive exploration of the 2500
year history of cognitive process training for
people with a variety of profiles of ability and
disability (Mann, 1979).
In this paper, we restrict our attention to only two
of these theoretical pillars, the Interacting
Cognitive Subsystems theory of information pro-
cessing and clinical intervention, and the self-as-
metaphor hypothesis.
As we have incorporated these theoretical
foundations and associated empirical evidence
into our clinical practice over a combined 40
years of serving this population, the following
critical intervention themes have emerged:
• Context: Intervention delivered largely outside
of the context of personally meaningful
themes, activities, settings, and interactions is
unlikely to have a lasting effect for people with
chronic cognitive and behavioural impairment.
13
 MARK YLVISAKER AND TIMOTHY FEENEY
• Everyday Routines: When appropriately
structured, the everyday routines of life are
the ideal context within which to deliver reha-
bilitation services and offer ongoing support.
• Everyday People: When everyday people in
the life of the person with TBI (possibly
including family members, work supervisors,
job coaches, direct care staff, and others) play
their support roles effectively, rehabilitation
is ongoing and appropriately contextualised.
• Apprenticeship Teaching: Using the
Vygotskyan apprenticeship approach to
teaching and cognitive development, relevant
information and skills are acquired as the
individual is engaged in meaningful tasks
designed so that the target information or skill
is processed during completion of the task
and in order to achieve the goal of the task.
The facilitator provides needed supports and
mediation at the outset, systematically
removing the supports as it becomes possible
to do so. Success can be guaranteed if errors
or failure pose serious threats to learning.
Large numbers of learning trials may be
required, but not delivered through massed,
discrete, decontextualised training trials as
conceived in traditional training models.
• Collaboration: Associated with apprentice-
ship teaching is the principle that profession-
als interact with the people they serve in a
collaborative manner as well as with profes-
sional colleagues.
• Meaningful Engagement in Chosen Life
Activities: Our experience with several hun-
dred young adults with chronic impairment
after TBI has led us to conclude that interven-
tions are likely to fail in the absence of mean-
ingful engagement in chosen life activities.
• Reconstruction of a Satisfying Sense of Self:
The changes in ability profiles and activity
possibilities after TBI often necessitate
restructuring one’s schematic mental model
of self, a process that can be facilitated by
using powerful and personally compelling
self-metaphors and by ensuring a large
number of successful experiences associated
with the new model.
• Impairment, Disability (Activity), and
Handicap (Participation): Traditional rehabili-
tation attempts first to eliminate or reduce the
underlying neurologically-based impairment.
In the event of ongoing impairment, an attempt
is then made to reduce the associated func-
tional disability through compensatory strategy
training or task-specific training. In the event of
14
ongoing disability, an attempt is finally made to
reduce the associated handicap (i.e., increase
participation in chosen life activities) by creat-
ing environmental or task modifications and
modifying the supportive behaviours of others
in the environment. The approach that we have
used for individuals with chronic
cognitive, behavioural, and communication
impairment reverses this hierarchy. In some
cases, though not in all, long-term practice of
participation-enhancing and disability-reduc-
ing strategies results in automatisation and
internalisation of the strategies and ultimate
reduction of the underlying impairment.
Interacting Cognitive
Subsystems (ICS) Approach
ICS was originally developed by Barnard as a
comprehensive information-processing theoretical
account of varied cognitive phenomena, such as
verbal learning, text comprehension, and the like
(e.g., Barnard, 1985). The theoretical model
includes standard cognitive components (e.g.,
nine cognitive subsystems) and their interrelation-
ships. Three of the codes encode sensory informa-
tion (Acoustic, Visual, and Body-State codes),
two encode intermediate structural level descrip-
tions (Morphonolexical and Object codes), two
encode higher levels of meaning (Propositional
and Implicational codes), and two are action or
effector codes (Articulatory and Limb codes).
Information processing is based on storage within
code-specific storage systems and on the transfor-
mation of information from one code into another,
transformations that are learned on the basis of
regularities in experience. Teasdale and Barnard
(1993) offer detailed descriptions of this cognitive
architecture and illustrate its explanatory power in
relation to both normal cognition and clinically
significant phenomena.
From our perspective, the critical features of
the theory are its distinction between proposi-
tional meaning and implicational meaning, its
integration of emotion into theoretical accounts
of information processing, and the central posi-
tion accorded implicational meaning in the pro-
cessing of information and regulation of emotions
and behaviour (Teasdale & Barnard, 1993). The
Propositional code includes meanings that are
represented as discrete concepts (e.g., dogs as
four-legged animals) and the relationships among
them (e.g., dogs chase cats) Propositional mean-
ings are relatively specific, can be expressed by
literal uses of language, bear truth value, and are
supported or rejected on the basis of standard fac-

tual evidence. The knowledge structures encoded
in the Propositional code may include schemas
and scripts of some generality (e.g., a-going-out-
to-eat script), but tied to verifiable facts and rela-
tionships, not to affect. Propositional-level
knowledge structures contribute to the organisa-
tion of experience and efficiency of memory and
verbal expression, without engaging motivation
or directly influencing decision making. Much of
the stored knowledge typically referred to as the
semantic knowledge base or declarative knowl-
edge is included in the Propositional code.
In contrast, meanings stored in the
Implicational code are generic and holistic, cap-
turing deep regularities, themes, and interrela-
tionships in human experience. These meanings
do not map directly onto literal language, but
rather rely on indirect language for their expres-
sion, including metaphor, narrative, image,
symbol, poetry, parables and the like. Beliefs at
the implicational level (e.g., I am strong and
heroic; I am a worthless victim) are not evaluated
as true or false, but rather as motivating or dis-
heartening, productive or stifling, inspiring or
boring, calming or troubling, organised or dif-
fuse, personally compelling or personally repug-
nant (Teasdale, 1997).
Meanings stored in the Implicational code are
bidirectionally tied to emotion and affect. Thus,
visceral (somatic) states and emotions can trigger
and influence the development of beliefs at this
level (e.g., the negative emotions associated with
punishment can elicit and strengthen the implica-
tional sense of self-as-victim); conversely, attend-
ing to implicational-level representations can
induce emotions (e.g., thinking of oneself as a
person in control of one’s destiny can elicit posi-
tive emotional states). In this sense, the
Implicational code is directly tied to motivation,
decision making, and action.
Furthermore, complex implicational-level
representations, such as an elaborated sense of
personal identity, influence the processing of
apparently factual information. For example,
some apparently obvious “facts” (e.g., “I cannot
walk because of my brain injury”) may be auto-
matically rejected because of their incompatibil-
ity with important implicational-level beliefs.
Other beliefs (e.g., “the rehabilitation staff are
trying to make me an invalid”) may be fabricated
in an attempt to maintain important implicational-
level representations of self in the face of experi-
ences that threaten those representations.
Explanations of everyday information pro-
cessing are also enhanced within the ICS frame-
work. For example, auditory comprehension of
RECONSTRUCTION OF IDENTITY AFTER BRAIN INJURY
language, as a cognitive phenomenon, is under-
stood within ICS as (1) registration of sensory
information in the Acoustic code, (2) transforma-
tion to the Morphonolexical code for intermedi-
ate-level linguistic analysis, (3) comprehension of
the message’s literal meaning, evaluation of its
truth value, and storage as semantic meaning in
the Propositional code, and (4) higher level inter-
pretation of the message and its potentially
hidden meaning (e.g., threat or flirtation) in the
Implicational code. Implicational-level interpre-
tation may influence propositional-level interpre-
tation. However, separate storage systems are
hypothesised for the separate codes, explaining
the frequently observed disparity between propo-
sitional-level understanding of an event or unit of
discourse and its implicational-level interpreta-
tion and associated affective response.
Schematic mental models of experience and
of the self are constructed in the Implicational
code, representing relations among generic fea-
tures of experience, relations between recurring
experiences and their associated emotional states,
and procedural knowledge or action strategies
associated with the experiences. Propositional-
level knowledge about the self-as-object may
include a large number of objective biological
and biographical facts. However, the sense of
self-as-subject, complete with aspirations, stan-
dards, self-evaluations, emotional associations,
and related action strategies, is stored in the
Implicational code, with a multitude of connec-
tions to all other codes, including the sensory
code. Thus, for example, a specific tone of voice
in the speech of an authority figure may automat-
ically trigger a “self-as-victim” mental model and
the procedural strategies (e.g., flee or fight) asso-
ciated with that model.
ICS in Psychotherapy as
a Model for Rehabilitation
Applied to the treatment of depression, ICS offers
an explanation for the success of cognitive and
other therapies (e.g., physical exercise) when they
are successful (Teasdale & Barnard, 1993). ICS
also suggests an explanation for the frequent fail-
ure of cognitive therapy, understood as the
attempt to marshal factual evidence in opposition
to beliefs about the self that are judged to be the
basis of the depressed emotional state (Beck et
al., 1979). Because factual evidence, discussed
dispassionately, is represented only in the
Propositional code, there is no reason to expect
that it will automatically affect implicational-
level schematic mental models of the self, and
therefore no reason to expect that it will automat-
15
 MARK YLVISAKER AND TIMOTHY FEENEY

ically influence emotion or action. Teasdale and

Barnard (1993) describe a “depressive interlock”
or vicious cycle of depression that occurs when
depressogenic mental models (e.g., sense of self
as unworthy failure and of life as hopeless) are
stored in the Implicational code, fed by selected
body states that are associated with and intensify
the core mental model as well as by proposi-
tional-level negative facts (e.g., I did yet another
task poorly) that are selected for attention by the
core depressogenic mental model and recipro-
cally intensify the model.
These reciprocal transformations of meaning
among various information codes are at the core of
all controlled information processing, according to
the ICS model (Teasdale & Barnard, 1993). It is
also at the core of the vicious cycle of depression,
wherein core depressogenic beliefs generate their
own sensory and factual evidence base, which in
turn strengthens the core beliefs. In our experience,
a similar self-perpetuating vicious cycle is associ-
ated with escalating behavioural disorders in many
young adults with TBI. For example, a person upset
with restrictions imposed by the disability and by
caregivers may react negatively to the restrictions
and the sense of identity implied by the restrictions,
leading caregivers to increase their control, result-
ing in intensified negative reactions from the FIGURE 1
person with disability. Just as a depressed mental
A negative schematic model of self in the Implicational
state feeds itself with evidence generated by the code (e.g., Jason’s victim model) generates problem
mental model, so also negative behaviour and the behaviours when provocation (defined by that model) is
associated oppositional sense of identity can feed perceived. The problem behaviours produce negative
on themselves by creating a world in which the feedback in the environment, yielding negative somatic
mental model fits the facts, which in turn strength- effects and associated negative somatic markers, which
ens the mental model. Furthermore, once con- in turn intensify the negative schematic model. In addi-
structed, a negative mental model has the power to tion, negative somatic effects can be generated directly
from the model with no need for environmental feed-
trigger negative somatic states, feeding a self-sus-
back. At the same time, the model selects propositional-
taining loop that does not require negative feedback level meanings that fit and reciprocally strengthen the
in the environment. Figure 1, adapted from model. Based on Teasdale (1999).
Teasdale (1999), illustrates this analog to “depres-
sive interlock” in many individuals with TBI.
Psychotherapy, within an ICS framework, has Application of ICS to TBI Rehabilitation
as its primary task “to create, in situations that Severe TBI almost always results in some type and
might otherwise elicit maladaptive emotions, degree of persistent impairment, associated restric-
alternative schematic models (generic, implicit tions on activities and reductions in experiences of
meanings) that do not produce dysfunctional success (as judged by the person’s preinjury stan-
emotional reactions.” (Teasdale, 1997, p. 148). In dards). For example, a student accustomed to
this way, the vicious cycle or depressive interlock receiving As and Bs may struggle to earn Cs after
is broken. In the remainder of this paper, we the injury; an athlete may not be able to return to
argue that a critical component of rehabilitation favoured sports; a young person who enjoyed great
for many people with TBI is the process of help- popularity may see friends go their separate ways.
ing them construct alternative schematic models In situations such as these, the schematic mental
of the self that can be triggered automatically by model of personal identity undergoes inevitable
otherwise problematic stimuli and that are associ- modification, ranging from relatively minor and
ated with positive emotional states and socially helpful (e.g., “I used to be a person who succeeded
successful action strategies. with little effort; now I must try harder, use special

16

strategies, and sometimes seek the help of others”)
to wholesale and destructive (e.g., “I used to be
king of the hill; now I’m nothing more than a mis-
erable helpless victim”).
In some cases, like those presented later, the
person with TBI may fight heroically to maintain
a preinjury sense of self, intensely resisting the
identity implicitly communicated by rehabilita-
tion professionals whose focus is predictably on
the person’s disability and the changes in life
apparently mandated by the disability. This iden-
tity battle, often subconscious, runs the risk of
creating a dangerous new identity, namely that of
a person for whom a sense of strength and self-
control and other positive emotions are associated
only with a mental model of a person committed
to fighting against the control and restrictions
imposed by others. In such cases, positive out-
comes of rehabilitation may require the collabo-
rative construction of a mental model of self that
includes the required sense of strength and con-
trol, but at the same time accounts for the changes
in behaviour and life circumstances possibly dic-
tated by ongoing impairment.
These dynamics may, of course, be associated
with any acquired disability. With severe TBI,
typically associated with some degree of frontal
lobe injury, there is the added complication that
pre-existing mental models of self may be frag-
mented and new effective models may be hard to
construct because of damage to the frontal lobes.
It has been hypothesised for many years that pre-
frontal regions are instrumental in storing and
applying complex schemas, scripts, mental
models, or other Managerial Knowledge Units
that guide organised information processing, effi-
cient memory and retrieval, organised discourse,
and planful, goal-directed behaviour in complex
situations (Grafman, 1989).
With respect to the neuropsychology of
models of self and personal identity, studies of
patients with frontal lobe lesions have increas-
ingly suggested that prefrontal structures are crit-
ical for constructing and effectively using a
coherent model of the self, organised over time
and diverse experiences, to remember, integrate,
and interpret ongoing experience (Stuss et al., in
press). Specifically, the right hemisphere frontal
lobe appears to play a critical role in the repre-
sentation of self (Craik et al., 1999). “The right
frontal lobe does serve as a specific convergence
site for all of the neural processes essential to
affectively personalise higher order experience of
self and to represent awareness of that experi-
ence” (Stuss & Alexander, 1999, p. 223). Levine
has connected these theories of autonoetic con-
RECONSTRUCTION OF IDENTITY AFTER BRAIN INJURY
sciousness (i.e., consciousness of the self as a
continuous entity across time, Tulving, 1985) to
self-regulatory disturbances following TBI
(Levine, 1999; Levine et al., 1999).
ICS offers one effective resolution to Hans
Teuber’s famous “riddle” of the frontal lobes,
namely the curious dissociation between knowing
and doing (Teuber, 1964). When knowing is
understood as a Propositional code phenomenon
and doing is understood largely as a product of
Implicational code forces, the dissociation loses
some of its curiosity. If certain types of frontal
lobe injury weaken connections between these
two codes or if the schematic model of self stored
in the Implicational code is fundamentally at odds
with facts stored in the Propositional code, then
the dissociation described by Teuber is pre-
dictable rather than curious.
Self as Metaphor
With the psychological and neuropsychological
themes of the previous section as background, it
has become increasingly clear that effective brain
injury rehabilitation may require a planned and
organised effort at collaboratively constructing
one or more positive schematic mental models of
self. Facilitating this process with exploration of
concrete and personally compelling metaphors
has its basis in three related hypotheses: that all
thinking about the self is essentially metaphori-
cal; that social construction of identity through
metaphor is a natural developmental process; and
that people whose thinking has been rendered
concrete by frontal lobe injury may especially
benefit from identity construction using person-
ally meaningful and compelling metaphors, rep-
resented within concrete graphic organisers.
Lakoff and Johnson (1999) have argued per-
suasively that all thinking about the self is
metaphorical. For example, self-control is repre-
sented as object control (e.g., “I dragged myself
out of bed”, “You’re pushing yourself too hard”,
“He is not holding himself together”) or object
possession (“I lost myself in the activity”, “He was
in the grip of fear”) or location (e.g., “I was beside
myself”, “You’re really out of it today”, “He’s out
to lunch”). Personal integration and its opposite
are represented as physical intactness (e.g., “I’m
feeling very scattered today”, “You’re all over the
place”, “She’s perfectly centred”). The social self
is similarly represented with social metaphors
(e.g., “I’m at war with myself about this”, “You
need to nurture yourself; wean yourself; pamper
yourself”, “He needs to be true to himself, not let
himself down”). Lakoff and Johnson presented
17
 MARK YLVISAKER AND TIMOTHY FEENEY
many more examples from English and Japanese
to support their hypothesis that the self is a
metaphorical construct and that the metaphors are
rather consistent across cultures.
Identity Construction
Through Appealing Metaphors
From very early in development, parents help their
children construct a positive sense of self through
metaphor. For example, praising a toddler who
uses a potty chair by saying, “You’re such a big
boy!! You’re just like Daddy!! Good job!” has the
effect of contributing to an evolving mental model
of self and at the same time attaching positive
emotions to that model. Similarly, on the negative
side, ill-conceived reprimands can contribute to
the construction of a negative model of self asso-
ciated with negative emotions (e.g., “There’s the
klutz tripping over his own feet again!” “You’re
such a loser!” “Why do you always act like a cry
baby?”). When identity metaphors are constructed
out of carefully selected attributes of personal
heroes, the process is well designed for adoles-
cents or others at a generally adolescent level of
development, given the power of heroes and role
models in shaping adolescent identity and moti-
vating their behaviour (Conger, 1984;
Czikszentmilhalyi & Larson, 1984).
Metaphor and Comprehension
Across many cultures and many domains of
teaching, those teachers acknowledged to be most
effective are famous for their creative exploitation
of concrete metaphors, parables, narratives,
proverbs, and other analogical representations of
reality in explaining complex or abstract material.
For example, Socrates explained executive func-
tions to sports-minded students with his famous
charioteer metaphor: human reason is like a char-
ioteer struggling to control two unruly steeds, the
appetites and the passions. (Interestingly, the con-
cept of “executive functions” in modern psychol-
ogy is itself a metaphor, using an analogical base
more fitting for late 20th century students,
although both metaphors misleadingly suggest
that the executive dimensions of processing are
like a little man in the frontal lobes directing traf-
fic.) Similarly, Jesus explained hard-to-grasp the-
ological and moral concepts with simple stories
and metaphors (e.g., stories about fishing and
farming) that were familiar and compelling to his
uneducated audience. Moses, Solomon, Buddha,
Confucius, Lao Tsu and many other extraordinary
teachers who have influenced the lives of count-
less millions of people throughout history have
18
similarly relied on metaphor and parables to
explain their teachings and make them appealing.
In our work with young people with TBI, we
have similarly found metaphor effective in explor-
ing abstract or challenging concepts. Although
some texts in the psychology of language group
metaphor with other abstract uses of language,
requiring literal processing and, in addition, pro-
cessing of the indirect meaning, familiar
metaphors can be more concrete and require less
complex processing than a literal formulation of
the same content. The language of the streets, pris-
ons, and similar nonacademic linguistic venues is
richly metaphorical. For example, most familiar
curses are metaphors that do not require two
stages of processing for their interpretation. (See
Nippold, 1998, for a useful review of the develop-
mental literature on metaphor comprehension.)
In the absence of planned metaphorical recon-
struction of identity, unplanned reconstruction
often occurs and may not be positive or effective.
As a result, other apparently well conceived inter-
ventions may fail because the behaviours to be
trained do not fit with the person’s identity-defin-
ing, implicational-level mental model of self. For
example, practicing social skills in a therapy
group will predictably fail at the level of transfer
to everyday interactions if those social behaviours
are not consistent with the person’s underlying
sense of self. This important theme is illustrated
by the young adult who successfully practices
polite requests for clarification in therapy, but
never uses such a request in real life because his
model of identity dictates that all requests for help
are signs of weakness and incompetence.
Metaphor and Processing
Efficiency: Metaphoric Compaction
Because people with TBI often have reduced
working memory capacity, there is great value in
combining several procedures into one thought
unit. Metaphoric compaction is common in many
activities, including sports. For example, in base-
ball the “squeeze play” includes the following
procedures, all of which are represented automat-
ically when the play is sufficiently well
rehearsed: (1) The pitcher begins his wind up; (2)
The batter turns and squares to bunt; (3) The
pitcher releases the ball; (4) The runner on 3rd
takes off for home; (5) The batter bunts the ball;
(6) The runner crosses the plate.
Similarly, for Jason, described below, the
Clint Eastwood metaphor included in one thought
unit the following series of events and actions: (1)
recognise a socially volatile situation, (2) sense
specific provocation from another person, (3) do

not act, (4) appear calm and in control, (5) use a
simple script (e.g., “We can talk about this later”),
(6) leave the situation. Whereas six or even two or
three procedures may be too many for a person
with working memory impairment possibly com-
bined with catastrophic reactions to emotional
stimuli, one well-selected metaphoric thought
unit, automatically associated with the six proce-
dures, may be sufficient.
Concrete Organisation of Identity
Models Using Graphic Organisers
Graphic organisers, similar to the identity maps
presented later in this paper, have become a stan-
dard instructional support in both regular and spe-
cial education, and have been applied successfully
to cognitive rehabilitation after brain injury
(Ylvisaker et al., 1998). Language arts workbooks
for elementary school students are filled with flow
charts and other diagrams that graphically represent
the organisation of many forms of complex think-
ing and discourse, including narratives, similari-
ties-differences reasoning, character analysis,
scientific explanations, persuasive discourse, and
many more. The underlying premise is that people
unfamiliar with complex conceptual territory bene-
fit from a “map” that illustrates the way in which
that territory is organised. Because schematic
models of identity include many components that
would be difficult to grasp and remember without
clear organisation, graphic advance organisers may
facilitate the process of constructing the model and
remembering it. For this reason we developed
“identity mapping” (see below) as a component of
the intervention for those individuals who have
some degree of organisational impairment and who
are free of serious visual perceptual impairment
that might cause such maps to be confusing.
Automatising Positive Identity Models
Positive implicational-level models of self are not
automatically elicited by relevant situations in the
world (associated with sensory and visceral states
of the individual) without extensive practice and
a substantial history of positive experiences asso-
ciated with the new model (Teasdale & Barnard,
1993). For example, a person may respond habit-
ually to perceived acts of disrespect by verbally
or physically attacking the perpetrator of the dis-
respect. This automatically triggered action strat-
egy may be firmly associated with a schematic
mental model of self-as-victim connected with a
conviction that strength lies in counter-attack. A
newly constructed mental model of self-as-
master, connected with a procedural association
RECONSTRUCTION OF IDENTITY AFTER BRAIN INJURY
of strength with restraint, is unlikely to be elicited
by a threatening situation in the world without
many experiences of threat followed by an act of
restraint (associated with the self-as-master
model) followed by positive consequences and
positive emotional states. Ensuring that the
person has a large number of such experiences
brings in the entire apparatus of antecedent-
focused behaviour management, which we have
discussed elsewhere (Feeney & Ylvisaker, 1995,
1997; Ylvisaker & Feeney, 1998, 2000).
Case Illustrations
In the three case illustrations that follow, collabo-
rative identity reconstruction was a component of
a larger package of collaborative intervention and
support, designed to help the individuals succeed
in their chosen contexts of life. In each case, the
identity metaphor was collaboratively negotiated
and organised in conversation with the individual,
the components of the schematic mental model of
self were organised as concretely as possible, and
self-presentation on video tape was used to
rehearse and internalise the metaphoric sense of
self and also to communicate the identity and
associated strategies to other relevant people.
Jason
Elsewhere we have used Jason’s instructive history
to illustrate specific aspects of brain injury rehabil-
itation (Ylvisaker & Feeney, 1996, 1998, 2000). In
this paper we focus only on identity reconstruction,
a critical component of his successful rehabilita-
tion. Prior to his injury at age 24, Jason had been a
reasonably successful student and hard worker,
often working two jobs to support the activities that
he enjoyed. He also had a long history of opposi-
tional behaviour, including conflicts with family
members and peers, serious behavioural difficulties
at two universities, including an expulsion for com-
bative behaviour, abuse of alcohol and drugs, and
discharge from the marines because of his com-
manding officer’s concern about potential noncom-
pliance under battle conditions.
Jason was hit by a car while riding his motor-
cycle, incurring widespread brain injury, includ-
ing bilateral frontal lobe damage. He remained
largely unresponsive for about six weeks, and con-
tinued to receive acute inpatient rehabilitation ser-
vices for an additional six weeks. At that time, he
discharged himself against medical advice and
attempted to resume his preinjury life. Although
his injuries were severe, including prolonged
coma and several orthopedic injuries that required
a series of surgical interventions, Jason’s cognitive
19
 MARK YLVISAKER AND TIMOTHY FEENEY
recovery from a psychometric perspective was
good, although probably depressed relative to
preinjury levels. Three years postinjury he attained
a Full Scale IQ of 109, above average performance
on the Wechsler Memory Scale, and satisfactory
performance on measures said to be sensitive to
executive system impairment. Persistent disability
in real-world situations included mildly slowed
processing, mild memory problems in demanding
real-world tasks, and significant executive system
weakness, including difficulty with planning and
organising, mood regulation problems, severe
impulsiveness, and inefficiency in learning from
consequences. This disparity between psychomet-
ric and real-world performance is reminiscent of
classic frontal lobe patients, such as EVR
(Damasio, 1994; Eslinger & Damasio, 1985). In
addition, Jason had received a number of psychi-
atric diagnoses associated with his multiple admis-
sions to psychiatric hospitals.
Jason has characterised the next four years of
his life as a downward spiral of failure, frustration,
anger, anxiety, depression, and defiance. During
those four years he married and quickly divorced;
attempted work, but could not maintain employ-
ment; returned to school, but could not succeed
academically. Several acts of violence (including
two that involved guns) and attempts at suicide led
to multiple incarcerations and admissions to psy-
chiatric hospitals. Jason spent most of his fourth
year postinjury, the year before we began to work
with him, in jail and psychiatric hospitals.
Through the New York State TBI Behavioral
Support Project, we worked with Jason to support
his community reintegration and independent
living after these difficult four years. A long
series of conversations with Jason, all of which
took place in natural settings (e.g., in his home or
over breakfast in a diner), revealed that two
schematic models of identity had evolved over
the previous four years. Figure 2, Jason-the-
Victim, represents the sense of self that Jason
believed many members of the medical commu-
nity and others wished to impose on him. Much
of his resistance to ongoing rehabilitation and to
the compensations and modifications recom-
mended by rehabilitation professionals was dic-
tated by his negative reaction to this (for him)
implied identity.
Figure 3 represents the sense of identity that
Jason had come to accept as his true self. He rep-
resented this sense of self with a marine metaphor,
but included only selected aspects of marine iden-
tity for this model. The major themes of the model
were success, power, control, extreme actions and
beliefs, and uncompromising resistance to any-
20
FIGURE 2
The schematic model of identity (identity map) as Jason
perceived it to be implied by the controlling and conde-
scending behaviour of medical professionals and
others. He resisted this model.
body who chose to exercise control over him or
place unreasonable restrictions on his choices and
behaviour. In retrospect, Jason recognised that the
extreme actions and values associated with this
identity were in part a reaction to the identity that
he believed others wished to impose on him. The
acts of violence that resulted from the procedural
knowledge stored with this mental model were
acknowledged by Jason to be ultimately self-
destructive, but, like Carlito’s fateful decision,
were dictated by a sense of self securely stored in
his Implicational code.
As Jason was leaving his last psychiatric hos-
pitalisation and preparing for another attempt at
community living, we helped him make a self-
advocacy video tape (protocol in Ylvisaker et al.,
1998), designed in part to let potential community
support staff know who he was, what he valued,
and how they would need to act if they wished to
help him. As he produced and subsequently
watched this video, he began to fashion for himself
a new model of self, consistent with his cherished
themes of power, success, independence, and con-
trol, but also consistent with his need to work
extremely hard at directing himself to achieve suc-
cess as he defined it. He represented this identity
metaphorically as Jason-as-Clint-Eastwood, based
on the critical insight that, like Clint Eastwood,
Jason would now have to take seriously his roles as
both actor and director and, also like Clint

FIGURE 3
Jason’s accepted schematic model of identity (identity
map) as it evolved over four years postinjury in reaction
to his circumstances and the behaviour of others.
Eastwood, he would succeed by attaching positive
emotions, like strength and power over others,
with restraint, careful use of scripts, and effective
use of support personnel (see Figure 4).
Having created for himself an emotionally
compelling, metaphorically represented sense of
personal identity consistent with his goals, but
also with his executive system impairment, Jason
willingly worked at developing scripts, strategies,
systems of support, and explicit rules of self-
direction that he then practiced in his everyday
activities and interactions (Lewin, 1998; Ylvisaker
& Feeney, 1996). It is now five years later and he
reports that the Clint Eastwood metaphor was a
critical contributor to stopping his four-year
downward cycle of frustration, failure, anger, and
defiance. The compelling vision of self that it
offered not only made him receptive to the hard
work needed to habituate positive alternative
action strategies, it also automatically yielded
important procedures at those times of stress when
he otherwise would not have been able to retrieve
from memory a sequence of positive actions.
Jason’s life has become increasingly successful
over the past five years. He maintains a home
with his wife of one year and works with us as a
peer counselor and trainer for staff needing to
understand behaviour management after TBI.
Furthermore, Jason reports that with each passing
RECONSTRUCTION OF IDENTITY AFTER BRAIN INJURY
FIGURE 4
The positive schematic model of identity (identity map)
that Jason collaboratively constructed in an attempt to
be successful in community living despite residual
impairment.
year, the self-direction and positive interaction
scripts that he initially implemented with great
effort and external support, have become increas-
ingly automatic. An intervention that began largely
as a set of participation-oriented external supports
and environmental modifications gradually became
disability-reducing strategies that Jason used with
little external support, and finally, with a great deal
of practice, were internalised to effect reduction of
his underlying executive system impairment.
Furthermore, Jason now creates for himself
personal metaphors to help him succeed in situa-
tions in which he anticipates difficulty. For exam-
ple, during the anxious weeks preceding his
wedding, he imagined himself in a dust storm,
with the only intelligent strategy being to wait for
the dust to settle before making any important
decisions. Jason was recently honoured by the
Department of Health for his successful use of
department resources. He negotiated the ceremony
and associated interactions, which were extremely
stressful for him, by picturing himself as an officer
in the marines, complete with the formal attire,
posture, and script to match this rank. In his role as
peer counselor, Jason now works with us to help
other individuals with TBI reconstruct positive
schematic models of self with which they might
rebuild their lives after the injury.
21
 MARK YLVISAKER AND TIMOTHY FEENEY
An additional measure of success for Jason,
especially relevant in an era of cost containment,
is the dramatic reduction in cost for his services
and supports. Whereas in the fourth year follow-
ing his injury (the year before this intervention
began) his cost to the state exceeded $125,000US,
the cost had shrunk to about $2000US for the
fourth year after the intervention began.
Bill
Bill’s brain injury resulted from a fall from a fifth
floor window (a possible suicide attempt). Prior to
his injury, Bill had lived in homeless shelters or on
the streets, where he sold and used drugs. He had
been arrested several times on drug-related charges.
Reports indicated that Bill was an inpatient in an
acute care hospital for six weeks (including three
weeks in coma) and in acute rehabilitation for
approximately one year. Brain injury included
severe bilateral frontal lobe damage with additional
primary impact damage to the temporal and pari-
etal regions. A subsequent MRI scan revealed dif-
fuse bilateral degeneration of the dorsal and medial
frontal regions and dorsal occipital regions, with
significant ventricular enlargement.
Approximately five years postinjury, Bill’s
motor functions, including speech, were grossly
normal and psychometrically assessed cognitive
functions were only mildly depressed (Full Scale
IQ: 80). Functionally, he had ongoing visual-per-
ceptual problems, spatial and temporal orienta-
tion problems, and generalised difficulty with
planning and organising. Furthermore, he contin-
ued to evidence self-regulatory problems, includ-
ing impulsive and verbally aggressive behaviour,
outside the context of familiar routines.
At this time, Bill had successfully completed
a TBI-substance abuse program, was living in his
own apartment (with the support of an indepen-
dent living support counsellor as needed), had a
job in a supported employment setting, and regu-
larly attended Narcotics Anonymous and other
support groups offered by the program he had
recently completed. He valued his job and was
described by his supervisor as a hard worker, but
had ongoing difficulty accepting and interacting
effectively with co-workers with disability. When
we began our “LL Cool J” intervention with Bill,
conflicts at work were escalating, with reports
from both Bill and his independent living coun-
selor indicating that at least 50% of his days at
work were marred by peer conflicts that resulted
in punitive action from the supervisor, including
suspension from work.
Bill readily acknowledged that he was a
major contributor to these conflicts and that he
22
would prefer social interaction at work to be free
of conflict. However, he rejected out of hand sug-
gestions that he simply ignore or walk away from
perceived peer provocation. He said that his sense
of self and honour — and associated reactions to
provocation — were shaped on the streets in the
context of drug dealing and use. At best, walking
away from provocation caused him to feel con-
fused about who he was; at worst, it was an
abhorrent admission of weakness.
A brief exploration of heroes revealed that
Bill had profound admiration for the rap singer
LL Cool J, both as a performer and as a person.
Over the course of two or three conversations in
his home, we collaboratively organised an iden-
tity map that included values, goals, and action
strategies important to Bill, metaphorically
exploiting two importantly different and very real
aspects of the LL Cool J persona. Bill chose the
term Lyrical Lord to refer to the rapper and the
cool behaviours associated with that life style.
The other side of LL Cool J, the successful hus-
band, father, and business man, came to be
labeled LL the Business Man.
We briefly worked on associating feelings
and action strategies with both aspects of this
identity metaphor. In both cases, acting like LL
Cool J meant feeling cool, powerful, strong, con-
trolled, and confident. However, LL the Business
Man had to act in a planful manner, create scripts
in advance, direct himself to use the scripts, and
monitor his behaviour in relation to goals. In con-
trast, the Lyrical Lord, reserved for social situa-
tions, could dress and act cool, rap and speak in
rhymes, and tease peers. These components of the
identity metaphor are illustrated in Figure 5.
To communicate his plan to the work supervi-
sor, Bill created (with our assistance) a self-advo-
cacy videotape in which he explained the LL Cool
J metaphor and the mildly condescending script
that he had agreed to use to terminate unwelcome
peer interaction (“Talk to the hand; the ears aren’t
listening”) followed by turning away. Bill watched
this video several times in an attempt to internalise
the sense of self and associated scripts. In addi-
tion, his supervisor wrote “LL Cool J” on a small
cue card, which she inconspicuously showed to
Bill when she anticipated a possible negative
interaction. Bill also carried a small card with the
message “I need a place to go chill out,” which he
inconspicuously showed the supervisor when he
anticipated difficulty regulating his behaviour.
Serious altercations with peers were reduced to
zero at work, and for the next several months,
there were no reports of punishment.

FIGURE 5
The flexible schematic model of identity (identity map)
that Bill collaboratively constructed in an attempt to be
true to himself and also avoid peer conflict at work.
It is now approximately one year since this
intervention was initiated. A recent report from
work indicated increases in negative interaction
with peers, related in part to new workers in the
work setting and increased incidental contact
among peers. In addition, procedural drift was
reported, with the supervisor no longer using the
LL Cool J prompt as an antecedent control proce-
dure and Bill no longer using his chill-out request
or reviewing his self-advocacy videos at home. We
have therefore met with both Bill and the supervi-
sor, and are helping Bill to create a new self-advo-
cacy video in which he proposes ways to organise
social interaction at work to avoid conflict. We
highlight this resumption of the intervention
because of the frequency with which maintenance
intervention is required for this clinical population,
necessitating long-term monitoring systems.
Stan
Stan was raised in New York City where, accord-
ing to his report, he began to abuse alcohol and
subsequently drugs in junior high school. His
high school career was dominated by gambling,
drinking, drugs (primarily cocaine), and irregular
school attendance. He and his friends reportedly
robbed trucks and stripped cars in high school,
but he was never caught. After high school, he
RECONSTRUCTION OF IDENTITY AFTER BRAIN INJURY
worked odd jobs and continued to abuse drugs. In
his mid-20s he was arrested for extortion and
served four years in prison. Shortly after his
release, he violated parole and served another
four years in prison. After his second release, he
was chased by a police officer and fell from a
roof, incurring a severe TBI. Nine months of
acute hospitalisation and early rehabilitation were
followed by six years in a post-acute brain injury
facility. Following transfer to home, he was in
and out of short-term substance abuse programs.
At age 41 he was referred to a last resort TBI-sub-
stance abuse program, where we became increas-
ingly involved in his rehabilitation.
Salient features of Stan’s behaviour at this
time (10 years postinjury) were, on the positive
side, a high level of energy, a desire to help
others, an interesting sense of humour, and a
stated desire to turn his life around. On the nega-
tive side, he evidenced a number of ventral frontal
lobe signs: extreme impulsiveness, sexually inap-
propriate behaviour (including uninvited sexually
suggestive verbal and physical contact with
women), perseveration, an apparent inability to
learn from the negative consequences of his
actions, generally weak monitoring of his behav-
iour and its consequences, difficulty interpreting
the intent of others’ actions (typically reading
malicious intent into the actions of staff), spotty
and selective episodic memory, and an apparent
inability to connect his long-term goals in life
with his choices and actions. In addition, Stan had
an unstable view of his own brain injury, some-
times denying injury and sometimes excusing
behaviour because of his injury. Physically, he
had mild motor impairment (he walked with a
cane) and mild dysarthria, although his speech
was fully intelligible to familiar listeners.
Collaborative intervention designed to recon-
struct Stan’s mental model of self began after sev-
eral behaviour plans designed to reduce
unacceptable behaviour and increase successful
social interaction had failed. Not only were these
plans unsuccessful, each had come to be a provo-
cation for anger even though they had been cre-
ated in negotiation with Stan. Furthermore, at the
time that this intervention began, Stan’s trial reg-
imen of Prozac was being titrated with the goal of
discontinuing its use. The medication was judged
to increase rather than decrease problem behav-
iours. Subsequent experimental medication regi-
mens appeared to have little positive impact on
Stan’s behaviour.
Episodes of uncontrolled anger, sexual acting
out, cursing, threatening staff, and other negative
interactions were increasing. Because of these
23
 MARK YLVISAKER AND TIMOTHY FEENEY

120
Total

100
ofofTotal

80
%%
Interaction:
Interaction:

60
Negative

40
Negative

20

0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

3-days baseline; 7 weeks intervention

FIGURE 6
Stan’s percentage of total interactions with selected staff judged as negative. Three day’s baseline indicated over 90%
negative interactions. The first two weeks of intervention suggested substantial improvement. This was followed by an
apparent extinction burst, followed by inconsistent, but generally disappointing performance.

behaviours, Stan had been banned from several He used the metaphor of master mason to capture
nearby businesses and from a health care facility the critical aspects of this model of self. The mason
where he had received some services. As indi- metaphor was used because of its usefulness in
cated in Figure 6, more than 90% of Stan’s inter- relation to positive, controlled, successful action
actions with key individuals in the program strategies and because Stan had admired master
(including the director, nurse, and direct care staff masons during his earlier work in construction. He
with whom he had the most problematic interac- had no interest in sports, music, movies, literature,
tions) were judged to be negative at baseline (the or other potential sources of personal metaphors.
first three days on the graph). Negative interac- We then helped Stan make several self-
tions were defined as those that included angry instructional and self-advocacy videos, one of
accusations, perseverative complaining, sexually which included his explanation of these two
suggestive language or touch, and impulsive models of self and also several vignettes in which
demands for immediate attention. We chose to he demonstrated for himself interactions from the
track Stan’s interaction with individuals with perspective of both models. We identified the
whom he had a history of negative communica- onset of the intervention to be the day that Stan
tion, rather than the staff with whom he most began to watch these videos on a daily basis and
often interacted positively, because safe and suc- to receive nonthreatening reminders from staff
cessful community living demands self-control in based on the positive master mason identity that
difficult as well as easy social situations. Due to he had chosen. At that time he also was assigned
the severity of his behavioural disorder and one-on-one behavioural assistance, mandated by
apparently poor prognosis for improvement, the his negative behaviours but potentially counter-
director of the program and a consulting psychol- productive because of Stan’s association of mon-
ogist had recommended that Stan be transferred itoring with the activity of prison guards.
to a more restrictive treatment setting. As indicated in Figure 6, the data looked
The identity map in Figure 7 represents promising for the first two weeks of the interven-
Stan’s reflections about his internalised model of tion (negative interactions were reduced from over
self that had evolved over three decades of prob- 90% of the total to around 35%). Stan then visited
lematic behaviour, hardened in prison, and inten- home for several days during a national holiday.
sified by restrictions imposed by corrections and When he returned, negative interactions increased
rehabilitation professionals. Stan chose to label to close to the baseline rate, possibly representing
this identity with a vulgar name. In moments of an extinction burst. Over the next four weeks, we
calm reflection, he acknowledged that this was attempted to intensify the intervention by prepar-
not the identity he envisioned for himself and that ing a “momentum” video, including positive inter-
he wished he could change. However, he added action and praise from staff, designed to accelerate
that he did not know how he could change. internalisation of the positive model of self and the
The identity map in Figure 8 represents Stan’s associated positive emotions. At the same time,
reflections about the person he wanted to become. Jason, who had successfully negotiated a transfor-

24

FIGURE 7
The negative schematic model of identity (identity map)
that Stan collaboratively constructed in an attempt to
understand his ongoing conflicts and lack of success in
community living.
mation in his primary mental model of self similar
to that desired by Stan, began to spend time with
Stan with the goal of helping him understand that
his desired changes were not only possible with
effort, but also very satisfying.
Unfortunately, after seven weeks of the inter-
vention, Stan’s progress has been inconsistent
and generally insubstantial (see Figure 6). His
reaction to perceived provocation continues to be
anger, confrontation, and expletive-filled perse-
verative outbursts. In addition, sexually explicit
language and physical contact, although reduced
in frequency, continue to be reported.
Although the final results of this intervention
cannot be confidently predicted at this time, we
have included a potentially negative case illustra-
tion for several reasons. First, Stan’s case under-
scores the point that helping people to perceive
the world and their own actions in the world
through the lens of a revised sense of personal
identity is a major undertaking, potentially
requiring months of intensive and consistent sup-
port for success. This is particularly true if the
negative behaviour patterns and associated
schematic mental model of self have been “burnt
in” over many years of negative training. For
example, in Stan’s case, facing down provocation,
RECONSTRUCTION OF IDENTITY AFTER BRAIN INJURY
FIGURE 8
The positive schematic model of identity (identity map)
that Stan collaboratively constructed in an attempt to con-
trol his behaviour and improve his interaction with others.
having the last word, and walking away uninjured
constituted an extremely reinforcing sequence of
events during his many years in prison; con-
versely, turning away from provocation was per-
ceived as weakness and elicited in him negative
emotional states. Understood simply in terms of
his history of reinforcement, these patterns of
response are unlikely to be overtaken by more
positive responses in the absence of extensive
reinforcing experience with an alternative model
of self. Unfortunately, providing those reinforc-
ing experiences becomes increasingly difficult in
a world in which everyday communication part-
ners have been the object of the individual’s
ongoing verbal abuse.
Summary and Cautions
In the previous section, we presented three case
illustrations of the intervention theories and strate-
gies described earlier in this paper. In the first
case, the intervention had an importantly positive,
enduring, and generalised effect. In the second
case, the effect was specific and positive, but may
continue to require periodic intervention for main-
tenance. In the third case, the intervention may
have no lasting effect, although the jury is still out.
Table 1 summarises potential obstacles to the suc-
25
 MARK YLVISAKER AND TIMOTHY FEENEY

TABLE 1
Social Reconstruction of Identity: Obstacles, and Strategies to Overcome the Obstacles

Obstacles Strategies To Overcome The Obstacles

Oppositionality
Impaired Working Memory
Need For Repetition
Concrete Thinking
Need To Associate Positive Visceral
Feedback/ Somatic Markers With
New, Positive Sense Of Self
1. Self-Instruction
2. Self-Selected Metaphors
3. Peer Support
1. Metaphoric Compaction
2. Large Numbers Of Video Learning Trials For Habituation
1. Videotaped Negotiation For Repeated Reviews
2. Videotaped Self-Modeling
1. Graphic Organisers
2. Motivating, Familiar, Concrete Metaphors
1. Positive, Supportive Scripts For Everyday Communication Partners
2. Positive Role: Planned Achievement With New Identity
3. Momentum Video, Illustrating Success With The New Identity
4. Peer Support
5. Compelling Positive Metaphor

cess of this type of intervention and strategies that
may be used to overcome the obstacles.
A number of cautions regarding this interven-
tion should be highlighted. First, rehabilitation
clinicians untrained in principles and practices of
counselling psychology must team with an experi-
enced psychotherapist or counsellor in delivering
the intervention. In our judgment, collaboration is
the key, not assignment of the intervention process
to a psychotherapist working in isolation. Second,
some individuals may not be candidates for explo-
ration of identity models represented metaphori-
cally. Individuals who are extremely concrete in
their thinking and who therefore may not grasp
the metaphoric nature of the alternative identity
model may be excluded, as well as those with
multiple personality disorder. In our practice, we
have also terminated this intervention when the
person insisted on using an identity metaphor that
we considered psychologically dangerous. For
example, one young man who had been abused by
his father said that he would like to organise a pos-
itive identity map for himself using his father as
the analogical base; another, wracked by religious
guilt, insisted on using Jesus as his new identity
metaphor. In these cases, we proceeded with a
comprehensive program of intervention minus the
component discussed in this paper.
Caution must also be exercised so that the
goals and values organised within an identity map
are truly those of the person with disability. In the
case of our illustrations, all of the material in the
collaboratively constructed identity maps came
from the individuals with disability. The clinician’s
role was to facilitate identification of a compelling
metaphor and to help the person organise his most
reflective thinking about firmly embraced long-
term goals, the strategies that might facilitate
achievement of those goals, and the contextualised
practice needed to habituate those strategies.
Finally, members of this clinical group often
benefit from other interventions, including phar-
macologic management, in conjunction with
behavioural therapies, and should therefore be fol-
lowed by a psychiatrist or related physician with
expertise in pharmacologic management of behav-
ioural disturbances following TBI.
Application to Less Severe Disability
We have deliberately chosen to discuss a poten-
tially useful component of brain injury rehabilita-
tion as it applies to individuals who are
particularly difficult to serve because of their self-
regulatory disorder. Exploration of metaphoric
representations of self and associated action
strategies may also be useful for individuals with
less severe disability and disability that may not
directly include behavioural or self-regulator con-
cerns. For example, individuals with disability
associated with memory or language impairment
may not integrate helpful compensatory manoeu-
vers into their everyday life until they find a way
of representing those strategies as consistent with
an acceptable sense of self. For example, the strat-
egy of requesting clarification of another’s mes-
sage may be acceptable if framed as the
professional conduct of a sophisticated journalist
rather than a person with language processing
impairment. Similarly, producing periodic organ-
ised summaries of a conversation may become

26

appealing if framed as the behaviour of a success-
ful business executive rather than a person with
brain injury implementing a memory strategy.
Because TBI disproportionately selects sports-
minded young men, we have made extensive use of
sports analogies to explain and render palatable
compensatory strategies. More generally, the
metaphor of coach or self-coach has been helpful in
explaining executive or self-regulatory functions
and creating positive associations with the effort
required to improve self-regulation of behaviour.
Evidence of Effectiveness
To our knowledge, there exist no experimental
studies of the effectiveness of this intervention
strategy applied to TBI rehabilitation. Teasdale
and Barnard (1993) summarised empirical evi-
dence supporting their application of the ICS
model to the treatment of depression. In addition,
Ylvisaker and Feeney (1998) summarised a vari-
ety of empirical supports for the general approach
to TBI rehabilitation described in the opening sec-
tion of this paper. They also offered several posi-
tive single subject experiments and case studies.
The general contextualised, collaborative,
antecedent-focused approach to TBI rehabilitation
for the population under examination can also be
supported as cost effective. During the fiscal year
1996-97 (the most recent year for which financial
analyses are available), the program through
which we deliver our services cost $144,000US.
Based on conservative New York State Health
Department calculations, the program saved the
state $1,486,000 during that year (a savings of
about $10 for every $1 spent). Cost effectiveness,
combined with solid theoretical support and sug-
gestive case material, provides motivation for con-
trolled experimental investigation of the
effectiveness of the intervention.
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