Brain Injury, August 2007; 21(9): 913–923

Treatment to improve self-awareness in persons with acquired

brain injury

YAEL GOVEROVER1,2, MARK V. JOHNSTON3, JOAN TOGLIA4, & JOHN DELUCA2,5

1
Education and Human Development, Department of Occupational Therapy, New York University, Steinhardt School
of Culture, New York, USA, 2Kessler Medical Rehabilitation Research and Education Center, West Orange, NJ, USA,
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3
College of Health Sciences, University of Wisconsin–Milwaukee, Milwaukee, WI, USA, 4Graduate Occupational
Therapy Program, Mercy College, Dobbs Ferry, NY, USA, and 5University of Medicine and Dentistry of New
Jersey–New Jersey Medical School, Newark, NJ, USA

(Received 26 April 2007; accepted 4 July 2007)

Abstract
For personal use only.

Aim: To examine the effects of an awareness training protocol embedded within the practice of instrumental activities of
daily living (IADLs) in participants with acquired brain injury on levels of self-awareness and functional performance.
Methods: This study used a randomized control trial design: 10 participants with moderate-to-severe brain injury received
six sessions of the self-awareness training while they performed IADLs (experimental group) and 10 participants performed
the same IADLs but received conventional therapeutic practice (control group). In the experimental group, participants
were asked to predict their performance before each task performance and to estimate their performance level after the
performance.
Outcome measures: Pre- and post-intervention outcome measures taken from the two groups were compared. Instruments
were standardized measures of ‘general’ self-awareness with collateral reports by informants (e.g. Awareness
Questionnaire); ‘task-specific’ self-awareness (e.g. Assessment of Awareness of Disability) and Self-Regulation Skills
Inventory (SRSI). Performance on IADLs was assessed using the Assessment of Motor and Process Skills (AMPS).
Results: Compared to the control group, the intervention significantly improved IADL performances and self-regulation. No
significant treatment effect was observed for task-specific self-awareness, general self-awareness or community integration.
Conclusions: The self-awareness intervention significantly but selectively improved self-awareness during IADL task
performance as well as functional performance. The need for a larger study with more treatment sessions is discussed.

Keywords: Self-awareness, activities of daily living, brain injury, rehabilitation

Introduction neurological dysfunction includes lack of knowledge

Lack of self-awareness of cognitive, behavioural and
emotional impairments has been reported to be one
of the greatest obstacles in brain injury rehabilitation
[1, 2]. Self-awareness and self-regulation are com-
monly impaired following brain injury, as both are
constructs associated with executive functions
and related to frontal-executive systems dysfunction
[3, 4]. Impaired self-awareness associated with
about one’s own physical or cognitive-perceptual
impairments and/or the functional implications, as
well as inability to anticipate difficulties, recognize
errors or monitor performance within the context of
an activity [5].
Many individuals with brain injuries appear to be
entirely or partially unaware of the impairments they
have developed as a result of their injury [5–9].

Correspondence: Yael Goverover, PhD, OT, Assistant Professor, Department of Occupational Therapy, Steinhardt School of Culture, Education and
Human Development, 35 West 4th Street, 11th Floor, New York University, New York, 10012, USA. Tel: 212-998-5854. Fax: 212-998-4044.
E-mail: yg243@nyu.edu
ISSN 0269–9052 print/ISSN 1362–301X online ß 2007 Informa UK Ltd.
DOI: 10.1080/02699050701553205
 914 Y. Goverover et al.
Blundon and Smits [10], for example, reported that
lack of insight and/or unawareness is among the
most frequent cognitive impairments observed in
adults with traumatic brain injury (TBI). Sherer
et al. [2] found that between 76–97% of post-acute
patients with TBI showed some level of
unawareness. This lack of awareness can impair the
individual’s ability to comprehend the impact of
one’s deficits on his/her ability to function in
daily activities [11–13], to benefit from
rehabilitation [9, 14–17] and to successfully return
to work [2, 18, 19].
Although self-awareness plays an important role in
everyday life, research has been limited largely to the
effects of unawareness in meeting rehabilitation
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goals. Researchers have consistently emphasized
the importance of understanding the roles of self-
awareness and self-monitoring in rehabilitation out-
come and the contribution of neurological and
psychological factors contributing to deficits in self-
awareness following TBI [20]. Very few studies have
systematically investigated the effectiveness of self-
awareness training on outcome [21, 22]. To date,
there have been limited empirical investigations of
the effectiveness of intervention strategies in improv-
For personal use only.
ing self-awareness and functional outcomes in
rehabilitation [23].
Within the body of self-awareness treatment
research, different methods of interventions have
been used to examine treatment effects on levels of
self-awareness of individuals with brain injuries. For
example, researchers have examined awareness in a
group training approach [24, 25] and found that
group therapy programmes have great potential to
increase intellectual awareness (i.e. patients’ ability
to recognize his/her deficits and/or impairments
[26]). Other studies have used educational board-
game formats [27, 28], concluding that using board
games in interventions may be beneficial in provid-
ing education and improving understanding of the
participants’ impairments, thus improving intellec-
tual awareness. Some studies have used observation
and feedback to improve participants’ self-awareness
of their impairments [29–32]. These studies support
the use of performance and feedback in individual
therapy to improve self-awareness. However,
Bieman-Copland and Dywan [33] reported negative
experience with behavioural therapy, namely direct
confrontational feedback, because it led to increased
agitation among their participants with severe brain
injury. Lastly, studies [21, 34, 35] used self-
awareness training in the context of functional
everyday activities. They used self-prediction,
self-evaluation, education, verbal and video-taped
feedback during the performance of real-life occupa-
tional performance in naturalistic therapy environ-
ments. Results showed increased self-awareness and
a decreased percentage of errors. Occupation-based
self-awareness studies support the premise that
awareness gradually emerges within activities that
are familiar because clients have a benchmark of
comparison for self-evaluation. Most of the studies
that were reviewed used a single-case design or used
a very small sample size, sometimes without a
control group (e.g. [22, 31]). Thus, there is a need
for more randomized controlled studies on the
effectiveness of interventions to improve self-
awareness.
The treatment approach utilized in the current
study was based on the Toglia and Kirk [5] model of
self-awareness. Toglia and Kirk [5] described an
interaction between ‘general’ self-awareness or
knowledge of and beliefs about one’s abilities (i.e.
‘self-knowledge’) and ‘task-specific’ self-awareness,
awareness that is activated during a specific situation
or performance of a task (i.e. ‘on-line awareness’).
Thus, Toglia and Kirk’s self-awareness model
emphasizes the importance of experiencing different
tasks from different domains to increase self-aware-
ness. Furthermore, they indicate that there is a
dynamic relationship, rather than hierarchical,
between knowledge, beliefs, task demands, the
context of a situation, metacognition and awareness
[5]. Some existing studies lend support to Toglia
and Kirk’s multidimensional model of self-awareness
[36–40].
The current pilot study is a randomized controlled
study of a self-awareness treatment approach based
on Toglia and Kirk’s model. The self-awareness
treatment used in this pilot study emphasized the
importance of experiencing performance with a
variety of tasks from different functional domains
to develop better self-awareness. Toglia and Kirk’s
[5] model suggests that awareness is a multidimen-
sional concept and that structured practice within
different functional activities can lead to improved
online awareness.
The primary aim of the present pilot study was to
investigate the use of an occupation-based interven-
tion that employed self-awareness and verbal self-
regulation strategies during the performance of
functional daily living tasks to alleviate difficulties
related to self-awareness and self-regulation and to
address functional performance outcomes.
Specifically, it aimed to test the efficacy of a self-
awareness retraining intervention in persona with
acquired brain damage.
It was hypothesized that, compared to the control
group, participants in the treatment group would
demonstrate significantly greater improvements in
proximal outcomes, specifically in: task-specific self-
awareness; self-regulation skills; actual functional
activities—the cognitive aspects of performance; and
satisfaction with the care provided in this
 Treatment to improve self-awareness in persons with acquired brain injury 915

Table I. Sample characteristics.

Experimental (n ¼ 10) Control (n ¼ 10)
2 p

Demographic characteristics
Current age (years) 39.5
11.6 39.2
13.8 0.003 0.95
Education (years) 13.9
2.2 15.0
3.0 0.84 0.37
Gender (%) 0.00 1.0
Male 80% 80%
Female 20% 20%
Race (%) 0.40 0.81
Caucasian 70% 80%
African American 20% 10%
Hispanic 10% 10%
Marital status (%) 1.4 0.69
Single 40% 40%
Married 40% 30%
Divorced 20% 10%
Widowed – 20%
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Injury descriptors
BI type/cause 7.4 0.11
Car accident 20% 30%
Violence 10% 10%
Pedestrian 50% 0%
Aneurism 30% 50%
Fall 0% 10%
Time since injury (months) 12.9
9.4 8.6
6.8 1.3 0.25
Glasgow Coma Scale (at admission) 4.6
1.6 3.6
.57 0.82 0.40
For personal use only.

experiment. Possible effects of the intervention on
more distal outcomes were also tested, specifically
whether the intervention leads to significant
increases in general self-awareness, actual functional
activities (especially the motor aspects of perfor-
mance) and reports of community integration.
Methods
Design
The design of this study was a single blind
randomized clinical trial. All participants were
assessed at baseline and then were assigned ran-
domly to either a treatment or a control group.
One day following completion of the six treatment
sessions, participants were assessed again.
Participants were not informed whether they were
assigned to the treatment or control group.
Participants
Twenty participants with a diagnosis of acquired
brain injury between the ages of 18–55. Participants
were living in the community (non-institutionalized)
and were recruited from an outpatient cognitive
rehabilitation programme. Participants were medi-
cally stable and oriented to person, time and
community. They were independent in basic activ-
ities of daily living (ADLs) as determined by the
Functional Independent Measure (eating, feeding,
dressing and communicating) [41] and had some
evidence of self-awareness impairment identified by
a treating therapist. Participants were able to attend
to a task for at least 20 consecutive minutes and
to follow simple one-step instructions. Participants
were excluded if they had aphasia and/or severe
visual problems or a primary psychiatric or substance
abuse diagnosis based on reports by their treating
physicians and therapists.
Demographics and injury characteristics of the
two groups (experimental and control) are provided
in Table I. Participants did not differ statistically
in age, level of education, time elapsed since the
injury (in months) or Glasgow Coma Scale score at
admission. The sample was predominantly male and
Caucasian; the number of males and females in both
groups was equal (eight males and two females
in each group). Cause of injury included road
accidents, falls, aneurisms and violence in both
groups.
Assessment instruments
Assessment of awareness of disability (AAD)
[42]. The AAD measures task-specific awareness
and is used in conjunction with the Assessment of
Motor and Process Skills (AMPS). The AAD
measures task-specific awareness by assessing the
discrepancy between the observed level of skill
(based on the AMPS) and that reported by the
persons themselves for specific ADL tasks [43].
 916 Y. Goverover et al.

The evaluator first watched the participant motor and process performance [46]. The MFR
perform two ADL tasks from the AMPS battery. model took into account the task challenge, rater
Immediately after completion of the task, the severity and item difficulty when estimating the
participant was asked seven questions about his/her participant’s final ADL motor and ADL process
performance of the two tasks and the evaluator ability.
recorded the participant’s responses. After scoring
the AMPS, the evaluator then assessed the discre-
Satisfaction with quality of care. This was measured
pancy between the observed problems in ADL
using a modification of standard questions used
performance and the participant’s own report of
elsewhere [47]. Participants rated their satisfaction
the problems experienced. This discrepancy ranged
with the treatment on a scale of 1–5, where 1 is poor
from 0 ¼ ‘the patient completely denies his/her
and 5 is excellent. In addition to this rating, two
disability’ to 4 ¼ ‘the client has a completely realistic
open-ended questions were asked: ‘What was good
opinion of his/her disabilities’, based on their
about the treatment you received?’ and ‘What could
performance of the ADL tasks. Response scores
be improved about the treatment you received?’
were summed to produce a summed score for the
The dependent variable was the participants’ rating
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seven questions, with sums ranging from 0–28.

on the 5-point Likert satisfaction scale

Self-Regulation Skills Interview (SRSI) [44]. The

Awareness Questionnaire (AQ) [48]. The AQ was
SRSI is a semi-structured interview composed of six
designed to measure impairments in general self-
questions that assess metacognition related to
awareness following TBI. The AQ score is based on
difficulty in life. Participants were asked to select
responses to two forms, one completed by the person
one main area of difficulty (e.g. memory problems,
with TBI and one by a clinician (i.e. therapist,
impaired attention and concentration, depression,
physician) familiar with the person with the TBI.
poor anger management, lack of motivation, anxiety
The self-rated form includes 17 items while the
For personal use only.

or reduced communication skills) and were then

clinician form includes 18 items. On each form, the
asked six questions related to their capacity to self-
abilities of the person with TBI to perform various
monitor or to recognize and anticipate difficulties
tasks after the injury, compared to before the injury,
relating to the chosen aspect of functioning. Each
are rated on a 5-point scale ranging from 1 ¼ ‘much
question was scored using a 10-point rating scale
worse’ to 5 ¼ ‘much better’. Questions address
where scores reflect levels of awareness, self-rating of
motor/sensory, cognitive and behavioural/affective
readiness to change (or motivation) and strategy
deficits. The clinicians’ ratings of patient functioning
(knowledge or use). Scores were summed and
were summed and subtracted from the patient’s
averaged and ranged from 0 (very high) to 10 (very
self-rating. The difference scores indicate impaired
low), based on guidelines by Ownsworth et al. [44].
self-awareness: the larger the difference scores, the
greater the likely impairment of self-awareness.
Assessment of Motor and Process Skills (AMPS)
[45]. The AMPS is an observational perfor-
Community Integration Questionnaire (CIQ)
mance-based assessment that is used to measure
[49]. The CIQ consists of 15 items assessing
motor and process aspects of a person’s performance
home integration, social integration and productive
of ADLs and IADLs. Participants were observed
activities. The CIQ is scored to provide sub-totals
performing two tasks of their choice, selected from
for each of these sub-scales, as well as a total
83 available tasks. Effort, efficiency, safety and
community integration score. Questions are based
independence of performance were rated.
primarily on the frequency of performing activities or
Performance was also rated in terms of 16 aspects
roles or on whether participants perform these with
of motor skill and 20 aspects of process skills
others or alone. In this study, the overall community
exhibited during the activity. Process skills indicate
integration score, computed by summing the scores
how the participant goes about performing an
from individual sub-scales, was employed. The
activity; that is, these skills reflect cognitive aspects
overall score ranged from 0–29, a higher score
of performance. Each aspect of motor and process
indicates greater integration.
skill was rated on a 4-point scale (1 ¼ severe deficit;
2 ¼ inefficient; 3 ¼ questionable and 4 ¼ competent
Intervention
skill). Performance was measured in terms of overall
independence as well as motor and process compo- Six individualized treatment sessions were adminis-
nents. Based on a Multifaceted Rasch Measurement tered over 3 weeks, with one session per day on 2–3
(MFR) model, a computer program converted the days of each week. Each session consisted of a
raw, ordinal data, into an equal-interval measure of maximum of 45 minutes and included the
 Treatment to improve self-awareness in persons with acquired brain injury
performance of one of the following Instrumental
ADL’s (IADL) per session: (1) prepare a
birthday gift; (2) prepare a lunch box; (3) pay a
telephone bill; (4) make a doctor appointment; (5)
arrange pills in a pill organizer; and (6) prepare a
birthday cake.
Experimental intervention. In the experimental
group, participants were asked to predict their
performance before completing each task. They
were also asked to assess their performance imme-
diately following the completion of each task. If a
participant identified a specific problem while
performing the task, he/she was asked to think of a
strategy to help make task performance better and
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easier.
Each intervention session involved several compo-
nents. Before task performance, the participants
were given a brief introduction to the IADL task
(e.g. preparing a lunch box, choosing and wrapping
a gift). Following this introduction, the participants
were asked to: (1) define their task performance
goals (e.g. ‘two types of food will be chosen out of
four, and placed into the lunch box’; ‘task comple-
For personal use only.
tion will take 35 minutes’); (2) predict task
performance (e.g. ‘rate the extent to which you feel
this task will be difficult’); (3) anticipate and pre-
plan for any types of errors or obstacles he/she
expects to encounter during task performance (e.g.
‘will this task require physical assistance; reminders,
etc . . .’); (4) choose a strategy to circumvent such
difficulties (e.g. written instructions, check list); and
(5) assess the amount of assistance he/she will need
to successfully perform the task. Following these
preliminary predictions and assessments, the parti-
cipant performed an IADL according to the defined
task goals. Immediately following task completion,
participants self-estimated their performance on the
task (e.g. task difficulty, time required for comple-
tion). Participants were asked to complete a struc-
tured self-evaluation of the task they have just
performed (e.g. ‘How difficult was it to choose the
appropriate items for the task?’). A discussion
between the researcher and the participant followed,
during which the participant described his/her
answers to the different questions asked and the
researcher described his/her observations and
answers to the same questions. After the discussion
participants were asked to write in a journal about
their experience in performing the task (i.e. the
difficulties they encountered, steps they used to
ensure task completion and their strengths and
weaknesses).
Control group. Participants in the control group also
attended six treatment sessions and performed
917
the same IADL tasks as the treatment group.
However, participants in the control group did not
receive the specific self-awareness intervention from
the therapist. These participants received conven-
tional practice, including direct corrective feedback
from the therapist on their performance (e.g. ‘please
choose another, more appropriate gift’).
Procedures
Participants were referred to the researcher by the
participant’s treating physician or therapist and
selected on the basis of the exclusion and inclusion
criteria stated above. The study was explained to
potential participants after they contacted the
primary investigator and if they expressed their
agreement to participate they were asked to sign a
consent form, approved by an Institutional Review
Board (see Figure 1 for procedures flow chart). All
participants first completed baseline testing as
described above. Participants were then randomly
assigned to either the control or experimental group
by the second author of this paper. Importantly, the
participants remained blind to group membership.
Following baseline assessment, all participants
underwent six therapeutic sessions (2–3 per week
over 2–3 weeks). During these sessions, the experi-
mental group performed IADL tasks with the self-
awareness treatment and participants in the control
group performed the same IADL tasks and got
corrective feedback from the therapist. One day after
the last treatment session, all participants completed
post-treatment testing which consisted of the same
assessments as baseline testing.
Data analysis
Initially, data were examined using descriptive
statistics. The dependent variables (i.e. task-specific
self-awareness, self-regulation skills and actual
functional activities) were analysed using a one-way
(treatment vs. control) analysis of covariance
(ANCOVA), using the baseline scores from the
dependent variables as covariates [50].
Results
Baseline comparisons
Independent samples t-tests were performed to assess
baseline equivalency on test performance between the
two groups (Table II). Results indicated no signifi-
cant differences between the experimental group and
the control group on any of the baseline measures.
 918 Y. Goverover et al.

Assessed for eligibility based on

inclusion/exclusion (n = 22) Excluded due to
failure to meet
inclusion criteria
(n = 2)
Base-line assessment (n= 20)

Randomized (n = 20)

Allocated to experimental Allocated to control group

group (n = 10) (n = 10)
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6 treatment sessions including self- 6 ‘treatment’ sessions with corrective

awareness feedback
1. Birthday gift preparation 1. Birthday gift preparation
2. Prepare a lunch box: 2. Prepare a lunch box
3. Pay a telephone bill 3. Pay a telephone bill
4. Doctor appointment 4. Doctor appointment
5. Arranging pills in a pill organizer 5. Arranging pills in a pill organizer
6. Prepare a birthday cake 6. Prepare a birthday cake
For personal use only.

Post-treatment
assessment (n = 20)

Figure 1. Flow diagram of the study procedures.

Table II. Test scores at baseline for all participants by group (experimental vs. control).

M (SD)

Experimental group Control group t

General self-awareness 11.6 (8.6) 13.3 (14.5) 0.54

Task-specific self-awareness 14.6 (6.9) 16.5 (7.6) 0.58
AMPS: motor score 1.1 (1.0) 1.5 (.81) 1.07
AMPS: process score 0.56 (.41) 0.77 (.55) 0.95
Self-Regulation Skills Interview 44.2 (8.8) 44.1 (10.8) 0.02
Community Integration Questionnaire 13.9 (2.5) 14.7 (4.4) 0.45

Table III. Effects of treatment on proximal outcome measures.

Post-test M (SD) ANOVA significance ANOVA significance

Factor E v. C F(1,19) p Pre–post r F(1,19) p Partial "2

Task-specific self-awareness 16.7 (7.0) 14.7 (7.8) 0.365 0.55 0.74 2.5 0.12 0.13
(AAD scores)
Self-Regulation Skill Inventory 6.2 (1.7) 7.7 (1.7) 4.28 0.05 0.67 9.3 0.001 0.35
(SRSI)
AMPS process score 0.87 (0.20) 0.64 (0.35) 3.33 0.08 0.50 9.5 0.01 0.36
Satisfaction with treatment 4.7 (0.5) 4.4 (0.8) 0.95 0.34 0.05 NA NA

*check df. Overlap with earlier table.

 Treatment to improve self-awareness in persons with acquired brain injury
11
10
9
8
7
SRSI scores
6 Experimental
5 Control
4
3
2
1
0
Baseline
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Figure 2. Changes in average SRSI self-regulation and metacognitive problems. Boxes indicate standard deviations; whisker lines indicate
range (highest and lowest scores). Higher scores indicate poorer metacognitive self-regulation skills.
Changes in proximal outcome measures
Table III presents statistical tests of the main
hypotheses, which deal with the effects of treatment
For personal use only.
on proximal outcome measures.
The first hypothesis addressed improvement in
task-specific self-awareness (AAD scores) in the
awareness treatment group compared to the control
treatment group following treatment. Differences
between the experimental and control groups in
AAD scores did not reach statistical significance
(p ¼ 0.12; "2 ¼ 0.13), although scores of the AAD
improved for the experimental group (change: þ 2.1)
and worsened for the control group (change: 1.8).
The second hypothesis was that self-regulation
would be better for the experimental group in
comparison to the control group following treat-
ment. Results of the ANCOVA indicated a signifi-
cant improvement in SRSI scores for the
experimental group, as compared to the control
group, after controlling for pre-test scores
(Table III). Participants in the experimental group
improved in self-regulation and metacognitive skills,
whereas participants in the control group had lower
SRSI scores post-treatment. These results are
graphically portrayed in Figure 2.
The third hypothesis was that functional perfor-
mance, especially the process/cognitive aspects of
performance, as reflected by the AMPS process
scores, would improve more with the experimental
treatment than with the control treatment. The
hypothesis was confirmed (p < 0.01). Participants in
the experimental group improved the process aspect
of their IADL performances, while participants in
the control group did not; participants in the control
group had worse process skills while they performed
919
Post-test
the IADLs. These results are graphically portrayed
in Figure 3.
The fourth hypothesis was that satisfaction with
the treatment would be greater in the treatment
group. However, no significant differences were
found between groups on satisfaction with the
treatment experience.
Changes in distal outcomes
Table IV presents the effects of treatment on more
distal outcome measures. On these measures one
expected to find a lower treatment effect than on the
proximal outcome measures effect, because the
distal outcome are affected by many confounding
factors.
Theoretically, one might expect that improvement
in awareness in a specific task would translate to
general self-awareness. As shown in Table IV,
however, there were no significant differences
between the control and experimental groups in
terms of changes in performance on the Awareness
Questionnaire. In both groups there was no sig-
nificant difference between the baseline and post-
treatment evaluations.
One also expected to find a change in the motor
aspect of functional performance, associated with
the experimental treatment. No significant differ-
ences were found for the AMPS motor scores
between control and experimental groups in the
ANCOVA. Both groups improved their performance
on the motor aspect of IADL performance (0.39 in
the experimental group and 0.19 in control group),
however the improvement was only significant in the
experimental group (paired t(9) ¼ 3.32, p  0.01, vs.
1.83, p  0.10).
 920 Y. Goverover et al.

1.6

1.2

SRSI scores
Experimental
0.8
Control

0.4

−0.4
Baseline Post-test
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Figure 3. Changes in the functional performance: AMPS Process Measure. Boxes indicate standard deviations; whisker lines indicate range
(highest and lowest scores). Higher scores indicate better process skills related to IADL performance.

Table. IV Effects of treatment on distal outcome measures.

Post-test M (SD) ANOVA significance ANOVA significance

For personal use only.

Factor E v. C F(1,19) p Pre–post r F(1,19) p Partial "2

General awareness–Awareness 10.4 (10.4) 13.5 (13.2) 0.31 0.59 0.88 0.11 0.74 0.01
Questionnaire
AMPS Motor Measure 1.51 (1.0) 1.76 (0.65) 0.41 0.53 0.92 0.78 0.39 0.04
Community Integration 13.3 (3.3) 13.6 (3.8) 0.03 0.87 0.71 0.04 0.85 0.003
(CIQ total score)

The same was hypothesized for Community
Integration, that community integration score
would be better following treatment. No significant
differences were observed between the control and
experimental groups on reports of their community
integration following intervention or associated with
the awareness treatment.
Discussion
The present study provides preliminary support for
self-awareness training in the context of functional
everyday activities for enhancing self-regulation
and functional gains for individuals with TBI and
acquired brain injury. It was hypothesized that
participants in the treatment group would demon-
strate significantly greater improvements in task-
specific self-awareness, self-regulation skills and
actual functional activities, especially the cognitive
aspects of performance. As expected, in this rando-
mized clinical trial (RCT), a significant effect of
treatment was evident for self-regulation and
functional performance (the cognitive aspect of
performance). A major part of this awareness
training was helping individuals gain control over
their cognitive symptoms so that they could antici-
pate or recognize the symptoms when they occur [8,
51, 52]. It is thought that understanding cognitive
weaknesses could lead to more effective use of
compensatory strategies and, in turn, to better
functional outcomes [25]. If a person does not
recognize a problem, he/she is not likely to self-
correct errors.
Another area of emphasis in the treatment studied
in this RCT was in restructuring knowledge and
beliefs about deficits through the integration of
direct and personal experiences. Personal experience
was achieved by practicing tasks of daily living,
specifically from the IADL domains. Thus, during
IADL performance, individuals were able to experi-
ence and recognize errors themselves, while achiev-
ing a sense of control and mastery over their
performance [19, 53]. Furthermore, structured
journaling was used at the end of each treatment
session, where participants were required to reflect
 Treatment to improve self-awareness in persons with acquired brain injury
on their activity experiences, identify challenges and
anticipate what they might do differently next time.
For these reasons, awareness training significantly
improved self-regulation, as well as better perfor-
mance of IADLs practiced during the treatment.
The authors also expected to observe a significant
change in task-specific self-awareness (AAD scores)
following treatment. That is, following treatment
participants in the experimental group would have
better task-specific self-awareness. Thus, partici-
pants would understand and acknowledge their
difficulties and their strengths of specific task
performance. There was a trend toward a significant
effect, with AAD scores improving in the experi-
mental group and decreasing in the control group;
Brain Inj Downloaded from informahealthcare.com by Northeastern University on 10/27/14
however, results did not show a statistically sig-
nificant change in the experimental group. Possibly
the effect would reach significance with a larger
sample size (also supported by effect size ¼ 0.13).
The unique focus of this RCT treatment was the
use of meaningful tasks to provide the participants
with experiential feedback that guide participants to
discover their own errors [54]. Therefore, satisfac-
tion with treatment was also hypothesized to be
higher in the experimental group compared to the
For personal use only.
control group because participants in the experi-
mental group would get a better sense of control
from the treatment than the control group and then
will be more satisfied. Results indicated that both
groups were highly and equally satisfied with the
treatment. This finding can be explained by the
personal communication that the participants in
both groups received from the researcher, and that
participants in both groups had to perform mean-
ingful tasks of IADLs. It is believed that performance
of IADLs is meaningful because there is an identified
goal and purpose [46, 55]; all the participants in this
study felt and reported that performance of IADLs
may resemble things that may be important for their
daily life functioning (some tasks less and some
more).
The improvements noted above (i.e. task specific
self-awareness, self-regulation and functional perfor-
mance) could potentially lead to better levels of
community participation and better general self-
awareness (i.e. the distal effects) [2, 5, 38]. As
expected, some improvements were found in the
distal effects; however, none of them were statisti-
cally significant. There are three potential reasons
why the changes in general self-awareness and
community integration were not statistically signifi-
cant. O‘Keeffe et al. [39] found that metacognitive
knowledge did not correlate with online emergent or
online anticipatory awareness. Thus, general aware-
ness and task-specific awareness are not correlated
and can be disassociated from each other. Based on
this, changes is specific self-awareness would not
921
change general self-awareness. The second explana-
tion relates to the intensity of the treatment
participants received in the present study. The
treatment offered in this study consisted of only six
treatment sessions. Perhaps more intensive, com-
prehensive treatment programmes are needed to
affect these distal outcomes, such as community
participation and general self-awareness. Future
studies should investigate the effect of a more
intensive programme on these distal outcomes.
The third explanation relates to the use of self-
report measures to examine self-awareness and
community integration. Although the CIQ and AQ
are psychometrically investigated measures of self-
awareness [48] and community integration [56],
there are some limitations in using these measure-
ments. These include the potential bias in partici-
pants rating themselves (CIQ) and therapist rating
their clients’ abilities (AQ) [22, 57].
Study limitations
A major limitation of this study was the small sample
size, with only 20 participants. With a larger sample,
perhaps some of the expected outcomes that were
not statistically significant could be significant (e.g.
specific self-awareness: AAD; effect size reported
0.12). The sample size was small because the
participants were recruited from a single centre
within a 12-month period. Another potential limita-
tion is related to the number of treatment sessions
individuals received in this study. Participants
received only six treatment sessions. It is desired to
have more treatment sessions together with follow-
up sessions to get more prominent and long-term
results [58]. Despite these limitations, statistically
significant improvements in self-awareness were
observed. Given the small sample size, increased
confidence regarding the findings of the present
study awaits replication.
Practical/clinical implications
The process of recovery and rehabilitation following
brain injury involves adjusting to and becoming
aware of changes in cognitive function that have
occurred as a result of the injury [5]. The results of
the present study indicate that a behavioural inter-
vention designed to improve self-awareness and
functional performance in persons with brain injury
with deficits in self-awareness resulted in a signifi-
cant increase in both functional performance and
self-regulation. Furthermore, results indicated that
RCTs are possible to perform in people with
acquired brain injury living in the community and
that even small RCTs can provide important and
significant information. This study has provided
preliminary data into the effectiveness of a new
 922 Y. Goverover et al.
treatment procedure to improve self-awareness and
functional performance. An advantage of this study
is the use of randomized assignment.
The clinical implications of this study, although
preliminary, are that training in self-awareness
should be incorporated into ordinary on-going
therapies used in rehabilitation in order to facilitate
awareness of and adjustment to acquired cognitive
limitations. Such training could be accomplished
through the practice of functional activities that are
neither too challenging nor too easy. Performance of
meaningful real world activities would provide the
patient with the opportunity to explore his/her
current level of ability, identify problems areas, set
realistic goals and select appropriate compensatory
Brain Inj Downloaded from informahealthcare.com by Northeastern University on 10/27/14
strategies. It is the authors’ belief that a more robust
treatment, with a follow-up in the person’s home,
that is directed towards priorities in the person’s life,
may be necessary to produce enduring improve-
ments in activity limitation and participation restric-
tion. Awareness training is only one step in a more
comprehensive treatment outcome model.
For personal use only.
Acknowledgements
The authors would like to thank staff members and
patients at the Cognitive Remediation Program at
Kessler Institute for Rehabilitation in New Jersey.
Special thanks to Ms Michele Spinazzola, MS,
OTR/L for her support and assistance. This study
was supported by National Institute on Disability
and Rehabilitation Research; Mary E. Switzer
Research Fellowship Program (Grant Award
Number: H133F0400180).
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