Self-awareness and self-regulation following acquired brain injury: Conceptualisation, treatment and development of an empirical model

Abstract

The increased survival rate following acquired brain injury (ABI) has emphasised the need to understand factors influencing the process of psychosocial recovery. Researchers suggest that deficits in awareness represent a significant barrier to recovery and constitute an important factor related to individuals' long-term psychosocial outcome. A second factor identified in the literature which influences long-term outcome involves self-regulation, or an individual's ability to use strategies to manage their post-injury difficulties. However, understanding of recovery has been hindered by an inadequate conceptualisation of factors underlying deficits in awareness and self-regulation. Theoretical models suggest that psychological and neuropsychological factors each make a relative contribution to deficits in awareness and self-regulation. Prior to the present research empirical studies had not examined the role of both psychological and neuropsychological factors within the same investigation.It is suggested that one main reason for the lack of development in this area is that standardised measures have not been available to examine levels of awareness and key self-regulation skills proposed by theoretical models. Study 1 of the present research addressed this limitation through the development and standardisation of the 'Self-Regulation Skills Interview' (SRSI). The subjects were a sample of 61 individuals with long-term ABI and 43 uninjured subjects as a comparison group. An analysis of the psychometric properties of the SRSI confirmed that it is a valid and reliable measure with the following three indices: Awareness; Readiness to Change; and Strategy Behaviour. Each index was also found to be correlated with a number of other standardised measures of neuropsychological functioning.Following the development of the SRSI, Study 2 (N=61) investigated the relative contribution of psychological and neuropsychological factors underlying deficits in awareness and self-regulation. Based upon theories of denial and personality, the role of psychological factors was assessed using measures of coping-related denial (SEC), personality-related denial (M-CSDS) and post-injury personality change (ICHII). Neuropsychological factors were examined using an estimate of general intellectual functioning and two measures of executive functioning which assess an individual's capacity for volition (ILS) and purposive behaviour (TTT). The findings indicated that neuropsychological factors had a more direct effect than psychological factors in contributing to deficits in self-awareness and self-regulation. Specifically, individuals with impaired executive functioning were more likely to show deficits in self-awareness and self-regulation compared to individuals within the normal range of executive functioning. Furthermore, the impact of high levels of both coping-related denial and personality-related denial was generally dependent upon level of executive functioning (i.e., impaired versus normal performance).Study 3 evaluated a group support program designed to enhance self-regulation skills and psychosocial functioning. Participants were involved in a 16-week group program with three assessment phases: pre-assessment (N=28), post-assessment (N=28) and a six months follow-up (N=26). Components of the program included clinically validated techniques for improving awareness and for self-management of post-injury deficits. The SRSI and a standardised measure of psychosocial functioning (SIP) were used to evaluate the program and results indicated that the participants significantly improved their level of self-regulation skills and psychosocial functioning at postassessment. Furthermore, such gains were maintained at follow-up.