Increasing Insight and Awareness in Traumatic Brain Injury (TBI)

Ask any professional who works in brain injury rehabilitation what the number one barrier to successful rehab is, and most likely you will get the same answer — lack of awareness or insight into deficits (anosognosia). The oil roughneck who sustained a brain injury from a fall who now has hemiparesis and sight in only one eye thinks he can safely go back to work on the rig. The rural postal carrier who has bilateral visual field cuts, impaired short- term memory, and impulsivity believes he can continue to deliver the mail in his truck. The architect who has no physical deficits, but impaired visual spatial skills, impaired working memory, and poor organizational skills thinks she can draw up perfect plans for a client. I have seen it time and again. It is the bane of therapists and frustration of families.

Given this pervasive issue in neurorehabilitation, what can we as professionals do to break through those walls of denial and help our clients gain even a glimmer of insight? I propose several strategies that have been successful for me and the neurorehabilitation teams with whom I have worked. Before we dive into those strategies, however, let’s briefly review the Levels of Awareness Pyramid as proposed by Crosson et al. 1989.

At the pyramid base is Intellectual Awareness, which is simply the client’s knowledge that they have a deficit and it could cause problems for them. An example of this would be the client who knows he “flies off the handle” when he thinks people are not listening to him. He may be able to admit this when questioned about it directly, or after an episode, when he may state he knows he has an anger issue. However, he is not able to prepare himself for when this might happen, nor is he aware of it as it is occurring.

The next level of the pyramid is Emergent Awareness. The individual has awareness of the problem as it is occurring. In the case of the client with the quickly triggered anger, he is likely to have the “oops, I did it again” moment as he is berating the Wal-Mart pharmacy clerk for not hearing him state his date of birth the first time she asks for it.

At the pyramid apex is Anticipatory Awareness. This is the goal for which many of us in neurorehab aim. At this level, the individual with the anger issue may realize as he plans to pick up a prescription, “I need to go at the beginning of the day before I am tired, and when the store is not as busy.” He is anticipating the noisy area and hurried clerks that may not hear him well, and he is planning a strategy to avoid having an anger issue.

So where do we go from here? For individuals at the Intellectual Awareness Level who deny they have any cognitive issues, one of my teams developed a “cognitive obstacle course”. This course included multiple stations that had to be completed with accuracy, and in a set time frame. Stations included assembly of an object from a schematic with no written directions, navigation of an automated phone tree, composition of an email to a family member or work colleague, doubling of a no bake recipe given written instructions for only a single serving, and packing of a suitcase for a trip involving one of two selected scenarios. Other stations were added in depending on appropriateness.

Having a veteran TBI survivor speak with the client and tell their story can also be helpful in the initial steps of addressing awareness. It often leaves a more lasting impression to hear from someone who has “talked the talk and walked the walk”. Plus, it lays the groundwork for discussing deficits.

You may recall the saying, “A picture is worth a thousand words?” Well, then a video surely must be worth a million. Prepare a task that will highlight the deficit you are wanting to address, and then video record it with the client’s permission. Review the video with them. Do this many times and in different situations. To up the ante, use a scale from one to five with one being very easy and five being very difficult. Ask them to rate themselves prior to executing the task. After reviewing the video together, ask them to rate themselves again. Compare the responses and discuss.

When addressing Emergent or Anticipatory Awareness levels, use the following self-evaluation questions with clients:

  • Before task:

How difficult will this be? Will I need to use any strategies? What strategies should I use? What problems might come up?

  • After task:

How difficult was this for me? How accurate was I? How much help did I need? What could I do differently next time?

These questions will hopefully prompt more strategic thinking and encourage development of a solution focused approach. The money shot is the final question after the task: What could I do differently next time?

Yet another strategy to employ is role playing in a group setting. I select another person to exhibit the problematic behavior or deficit. The client with reduced awareness has to intercede and assist the person through the issue. Video recording of the role play is encouraged here as well.

As a final tool in your awareness-building toolkit, make use of the Patient Competency Rating Scale (PRCS) by Prigatano, G.P. and Others (1986). It is free and reproducible on the COMBI (Centers for Outcome Measurement in Brain Injury) website ( The PCRS utilizes a Likert Scale from 1-5 to rate ability to complete certain tasks or to rate how much a problem is noted during certain skills. Three versions are available for the therapist, family member, and client to complete, then compare and discuss.

Anosognosia is a huge barrier to productive outcomes. We must fight it with the correct tool in our toolbelt. This means our creativity must be fully engaged as clinicians so that we discover the key that will unlock the door to our client’s success.

Crosson C, Barco PP, Velozo C, Bolesta MM, Cooper PV, Werts D, Brobeck TC. Awareness and compensation in postacute head injury rehabilitation. Journal of Head Trauma Rehabilitation. 1989; 4:46–54.

Prigatano, G. P. & Others (1986). Neuropsychological rehabilitation after brain injury. Baltimore: Johns Hopkins University Press.


Rene’ Mills, M.S., CCC-SLP, CBIST

Rene’ Mills is the Program Director for our Rocky Mountain Region programs with oversight of specialized rehabilitation program for adults with acquired brain injury and complex behavioral and rehabilitation challenges.