What SLPs Need to Know:
Awareness

 11 min read

Imagine being back home months after a brain injury, thinking life should be returning to normal. You cook dinner as usual, but you leave the stove on. You get lost driving to a familiar place and snap at a loved one for offering help. Everyone around you seems overly cautious, constantly pointing out mistakes you don’t even realize you’re making. To you, things feel fine—but your independence is slowly being taken away, and you don’t understand why.

Impaired self-awareness is the inability to recognize your own strengths and limitations after a brain injury. A similar condition is called anosognosia, which is used to describe reduced awareness of a specific impairment, like left neglect after a right-hemisphere stroke (Blake, 2018). According to Mamman and colleagues (2022), up to 97% of those with moderate to severe traumatic brain injury (TBI) experience reduced awareness. This is caused by a combination of physical and psychological factors (Terneusen et al., 2023) and is influenced by a person’s emotional state, culture, and values (Fleming & Osworth, 2006).

People with reduced awareness often don’t realize they need extra help. As a result, they might resist speech therapy because they don’t think there’s anything to work on. Motivation is a key factor to recovery, and it would be very difficult to stay motivated if you don’t understand why you’re in speech therapy in the first place. Much of cognitive-communication treatment is strategy instruction; again, why bother to learn or use a strategy if you don’t think there’s a problem?

Most studies confirm that poor awareness negatively impacts therapy outcomes (Robertson & Schmitter-Edgecombe, 2015). A systematic review by Dromer and colleagues (2021) reported that most studies “found poor self-awareness associated with poor rehabilitation, functional, social and vocational outcome and with increased burden on relatives.” Without insight, a person’s safety and independence are at risk.

Assessing Awareness

Given the potential impact, clinicians should assess awareness during the evaluation and address it early in the treatment process. A survey by Winkens et al. (2014) confirmed that clinicians know it’s important to evaluate awareness, but only a small number actually use a specific measure.

Consider the Awareness Questionnaire (AQ) or the Patient Competency Rating Form (PCRF) to look at awareness. Both free self-reported outcome measures include a patient rating form, a family member rating form, and a clinician rating form. Compare responses to get a patient-proxy discrepancy score: the difference between the patient’s score and that of the family member. The size of the discrepancy can provide insight into their awareness deficits (Dromer et al., 2021).

Clinician-led interviews, like the Self Awareness Deficits Interview (SADI – PDF), are another way to assess awareness. These measures, along with clinical observation, can not only identify a self-awareness impairment, but they can also point to broader executive dysfunction and social-behavioral challenges.

If awareness is intact, look out for signs of anxiety and depression. Awareness and mood have an inverse relationship— better awareness might mean higher emotional distress (Dromer et al., 2021).

1) Motivational Interviewing

Clinicians can use motivational interviewing for individuals with awareness deficits. This approach involves collaboration, patient autonomy, self-efficacy, and patient-centered goal setting (Medley & Powell, 2010). Clifford (2023)wrote a useful summary of tips for healthcare workers, such as:

• Use active listening (paraphrase and validate feelings)
• Provide affirmations to improve confidence
• Ask for permission before giving advice
• Ask for their ideas and opinions

In a randomized controlled trial, Bell et al. (2005) found that clients with TBI who participated in motivational interviewing improved in functional and subjective quality of life outcomes compared to a control group.

2) Meta-Therapy for Cognition

Similar to motivational interviewing, Tilton-Bolowsky et al. (2023) brought “meta-therapy” from the voice therapy space to cognitive-communication. A key component of meta-therapy is effective clinical dialogue, or how clinicians speak to their patients. The goal is to “get client buy-in, increase engagement, and improve treatment efficiency and outcomes more broadly.” Some fundamental rules of meta-therapy include:

1. Treatment rationales should be clear and in plain language.
2. Link therapy activities to real-life behaviors.
3. Be specific about actions you’ve observed instead of focusing on accuracy alone.
4. Let the patient’s responses to your dialogue or treatment approaches guide what to do next- be flexible.

3) Patient Education about Awareness

Build awareness by taking the time to educate patients about their brain injury – how it affects thinking, emotions, and daily life (Cicerone et al., 2022). When patients feel respected, informed, and included in their own recovery process, they’re often more willing to self-reflect. Use patient-friendly visual supports during this discussion.

Find a patient-friendly handout about awareness in the Resource Vault in the Virtual Rehab Center!

Focus on symptom indicators (e.g., forgetting appointments, losing track of time) instead of labels, like “executive dysfunction.” Remember to validate the patient’s feelings about the difficulties they’re experiencing since their injury (“Yes, it is stressful arriving late to work every day. That must be hard for you.”)

Keep in mind, not all patients will respond positively to education, especially those with denial or a defensive personality (Fleming & Osworth, 2006). In these cases, a behavioral approach might be best (Bieman-Copland & Dywan, 2000). This involves educating the patient on coping strategies (like relaxation techniques) before working on behaviors, and counseling to acknowledge the grief surrounding their injury.

If socio-cultural and environmental factors play a role in a patient’s unawareness, then educational groups, support groups, and peer mentoring programs are recommended, in addition to clinician-led education.

4) Metacognitive Strategy Training (MST)

Any metacognitive approach that involves self-monitoring and feedback can be used to address awareness (Jeffay et al., 2023). Providing these opportunities in structured, familiar tasks can help patients redefine their offline awareness– general knowledge about their own abilities (Fleming & Osworth, 2006). This process is generally referred to as “guided mastery” in the literature (Toglia & Goverover, 2022).

Clinicians can and should vary the actual tasks (e.g., enrolling in a class, filing documents, arranging childcare), but the learned metacognitive procedure should be constant to help make the process a habit (Fleming & Osworth, 2006). Try to choose tasks that will elicit errors to target awareness (Blake, 2018).

Metacognitive procedures usually include these elements before, during, and after a task:

There are two evidence-based treatments, Awareness Training and the Predict-Perform-Evaluate procedure, that include similar steps to improve awareness and address executive dysfunction.

Let’s take the task of packing a suitcase as an example. The patient would follow these steps:

In a randomized controlled trial, Goverover and colleagues (2007) found that the experimental group that received Awareness Training improved in self-regulation and performance during instrumental activities of daily living (IADLs). These changes were not reflected on the Awareness Questionnaire, so further studies are needed with larger groups and more treatment sessions.