Impaired self-awareness and brain injury

Lack of self-awareness is a common outcome for people who sustain brain injuries with frontal lobe damage. When this happens it becomes difficult for a person to assess his or her own ability and limitations, depending on the degree of injury. For example, someone might know they have a problem but do not recognise when it happens, or know how to respond. In other cases, a person may refuse to acknowledge that there is a problem at all. The person may believe that family members are lying or exaggerating the problems. This lack of self-awareness can lead to unrealistic goals such as returning to work despite a severe brain injury.

It is possible for a person to increase their level of self-awareness through rehabilitation. This can be challenging as people with a lack of self-awareness may not want to take part in rehabilitation for problems they don’t believe exist.  

Any techniques used to help increase self-awareness will depend on why there is a problem with insight in the first place. The main causes are: 

• an inability to assess and monitor one’s performance and abilities 
• concentration and memory problems are reducing insight 
• an inability to set goals and put strategies into action. 

Common techniques in rehabilitation include (Fleming & Ownsworth2006):  

• selecting key tasks and environments to highlight difficulties 
• providing clear feedback and structured learning opportunities 
• promoting habit formation through procedural learning 
• specifically training for application outside the learning environment 
• involving clients in group therapy 
• educating family and enhancing social environment supports 

Families can support the rehabilitation team by providing a consistent response to any problems arising from a lack of self-awareness. Some practical tips include: 

• provide non-judgmental feedback on their performance 
• provide positive feedback as well as pointing out issues 
• encourage them to analyse their own performance 
• link rehabilitation to personal goals (e.g. returning to work) 
• minimise potential risks such as driving and cooking 
• avoid arguments. 

In some cases, insight can develop over time if a person experiences repeated setbacks. While upsetting, periods of despair at being unable to regain skills and abilities can lead to an improvement in self-awareness. 

The inability to self-monitor and self-correct behaviour can lead to challenging behaviours after a brain injury. 

Partners and family members can feel frustrated if the person denies there is a problem. The person may not recognise when it occurs or have may trouble controlling their own behaviour. Where possible, the family should work with the rehabilitation team to respond consistently to challenging behaviour.