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Neuropsychological
Rehabilitation: An International
Journal
Publication details, including instructions for authors
and subscription information:
http://www.tandfonline.com/loi/pnrh20

Participant perspectives on an
individualised self-awareness
intervention following stroke: A
qualitative case study
a

b

Dr Tamara L. Ownsworth , Merrill Turpin , Brooke
b

Andrew & Jennifer Fleming

b c

a

School of Psychology and Applied Cognitive
Neuroscience Research Centre, Griffith University , Mt
Gravatt, Australia
b

Division of Occupational Therapy , The University of
Queensland , St Lucia, Australia
c

Occupational Therapy Department , Princess
Alexandra Hospital , Brisbane, Australia
Published online: 15 Oct 2008.

To cite this article: Dr Tamara L. Ownsworth , Merrill Turpin , Brooke Andrew
& Jennifer Fleming (2008) Participant perspectives on an individualised
self-awareness intervention following stroke: A qualitative case study,
Neuropsychological Rehabilitation: An International Journal, 18:5-6, 692-712, DOI:
10.1080/09602010701595136
To link to this article: http://dx.doi.org/10.1080/09602010701595136

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NEUROPSYCHOLOGICAL REHABILITATION
2008, 18 (5/6), 692– 712

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Participant perspectives on an individualised
self-awareness intervention following stroke:
A qualitative case study
Tamara L. Ownsworth1, Merrill Turpin2, Brooke Andrew2, and
Jennifer Fleming2,3
1

School of Psychology and Applied Cognitive Neuroscience Research Centre,
Griffith University, Mt Gravatt, Australia; 2Division of Occupational Therapy,
The University of Queensland, St Lucia, Australia; 3Occupational Therapy
Department, Princess Alexandra Hospital, Brisbane, Australia

Most research investigating the efficacy of neurorehabilitation has focused
upon pre- versus post-intervention functioning, which is important for evidence-based practice but overlooks the therapeutic process. Therefore, this
qualitative study aimed to investigate a participant’s perspective of experiences
in therapy throughout an awareness rehabilitation intervention. The participant
(CP), a young male with awareness deficits following a right thalamic stroke,
had repeatedly attempted to return to work and experienced recurrent periods
of depression associated with his employment difficulties. Throughout a
12-session rehabilitation intervention, which targeted self-awareness and
self-regulation skills, CP provided interview feedback concerning his experiences of different therapy exercises. The key themes emerging from the data
regarding CP’s perspectives included: understanding benchmarks and the
value of feedback, learning through practical exercises, and individualising
therapy. In collaboration with a disability employment support service, CP
achieved paid durable employment. This study highlights the importance of

Correspondence should be addressed to Dr Tamara Ownsworth, School of
Psychology, Griffith University, Mt Gravatt Campus, Nathan QLD 4111, Australia. E-mail:
t.ownsworth@griffith.edu.au
A Public Health Fellowship from the National Health and Medical Research Council and a
grant from the Centre of National Research on Disability and Rehabilitation Medicine jointly
funded the present study.
# 2007 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurorehab
DOI:10.1080/09602010701595136

PARTICIPANT PERSPECTIVES ON REHABILITATION

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considering participants’ perspectives of the therapeutic process to assist in the
design and evaluation of awareness rehabilitation interventions.

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INTRODUCTION
Inaccurate self-appraisal following acquired brain injury (ABI) can pose a
significant barrier to engaging clients in the rehabilitation process and achieving favourable outcomes (Toglia & Kirk, 2000). In a treatment context it can
be challenging to determine how best to target the development of awareness
of deficits while monitoring and supporting the emotional impact of this
process (Ownsworth & Clare, 2006). Over the past two decades empirical
evidence has emerged to support the efficacy of awareness interventions for
improving self-awareness and everyday functioning (Fleming & Ownsworth,
2006). However, research is yet to examine participants’ perspectives of the
therapeutic process during sessions throughout rehabilitation. Thus, the main
objective of this exploratory study was to identify participant perspectives of
therapy during an intervention designed to enhance self-awareness and selfregulation skills.

Awareness of deficits: Key concepts
A review of conceptual models suggests that awareness of deficits following
ABI refers to a broad range of interrelated metacognitive skills such as the
capacity to: (a) accurately appraise changes to self and one’s abilities, (b)
understand the functional impact of these changes (e.g., the implications of
deficits for independence or work), (c) set realistic goals, (d) recognise problems as they occur in day-to-day situations, and (e) anticipate that difficulties
related to particular deficits will be experienced in the future (Crosson et al.,
1989; Fleming, Strong, & Ashton, 1996). Toglia and Kirk (2000) made a
distinction between self-knowledge of deficits that exists prior to task
performance, and on-line awareness, involving the ability to recognise and
anticipate errors in-situ or during performance. They proposed that these
different aspects of awareness interact dynamically with personal characteristics (e.g., cognitive status, personality and coping style), the environment,
and task demands. Awareness of deficits is a particularly pertinent issue in
vocational rehabilitation.

Awareness of deficits and return to work
Awareness deficits are typically viewed as a barrier in the return to work
process, which influence goals and expectations and the ability to benefit

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from feedback and develop compensatory strategies in the workplace
(Ownsworth & Fleming, 2005). Ben-Yishay, Silver, Piasetsky, and Rattock
(1987) found that the ability to set realistic goals was one of the key predictors
of return to work outcomes following intensive holistic cognitive rehabilitation. Ezrachi, Ben-Yishay, Kay, Diller, and Rattock (1991) identified that
individuals’ acceptance of their injury during rehabilitation significantly
predicted work outcomes six months after the programme. Greater
acceptance of injury was associated with increased compliance with rehabilitation, active participation and willingness to disclose problems and
follow therapists’ recommendations. Such attributes in rehabilitation were
viewed as important in achieving employment outcomes due to promoting
realistic goals and expectations concerning work and the development of
compensatory strategies.
Longitudinal studies have identified a significant association between
awareness of deficits during rehabilitation and more favourable vocational
outcomes (Ownsworth, Desbois, Grant, Fleming, & Strong, 2006; Sherer
et al., 1998; 2003). Ownsworth et al. (2006) identified that individuals
who achieved competitive employment between an initial assessment
during rehabilitation and a 12-month follow-up experienced an associated
increase in awareness of deficits while individuals who remained unemployed displayed little change in awareness. While the direction of this
relationship was unclear, the findings emphasised the need to monitor
developments in self-awareness as they occur during rehabilitation and the
return to work process. It was further recommended that interventions
target self-awareness and self-regulation skills while supporting the
individual to cope with associated emotional reactions (Ownsworth et al.,
2006). Techniques for enhancing awareness of deficits include psychoeducation, peer support and group therapy, role reversal, systematic feedback, performance predictions and guided self-evaluation of performance
through participation on graded familiar tasks (Dirette, 2002; Fleming &
Ownsworth, 2006; Toglia & Kirk, 2000). In general, multi-faceted
approaches tailored according to an individual’s characteristics are recommended in the context of a broader programme designed to achieve
goals that are personally meaningful.

Participants’ perspectives of rehabilitation
In a systematic review of evidence-based cognitive rehabilitation Cicerone
and colleagues argued the need for future research to “move beyond the
simple question of whether cognitive rehabilitation is effective, and examine
the therapy factors and patient characteristics that optimise the clinical outcomes of cognitive rehabilitation” (2005, p. 1681). In terms of awareness
interventions, most studies have focused on an evaluation of outcomes with

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only select studies investigating participants’ perspectives of the process of
developing awareness of deficits in the rehabilitation context.
Qualitative research by Kristensen (2004) examined changing goals and
intentions during rehabilitation by interviewing participants before and
after a 4-month programme. The findings suggested that before rehabilitation
individuals generally strived to preserve “the former self” while after the programme individuals shifted towards self-autonomy, self-realisation and
adjustment to their current situation. However, due to the pre- post-design,
it is uncertain how this shift in self-presentation occurred. Further, Dirette
(2002) interviewed three individuals with ABI who had “good awareness
of cognitive deficits” and recently completed a day treatment programme.
These individuals retrospectively recalled the slow process of developing
awareness of deficits, which was triggered by critical events, and use of compensatory strategies. A recent qualitative study by O’Callaghan, Powell, and
Oyebode (2006) conducted semi-structured interviews with 10 individuals
receiving outpatient rehabilitation. Participants recalled that awareness of
deficits developed through personal discovery and other people’s reactions,
typically outside of the rehabilitation setting, and was associated with fear,
loss and grief. Rehabilitation assisted this process by explaining the effects
of brain injury, normalising experiences and supporting individuals to
accept their post-injury changes.
Overall, these studies reinforce the view that, from the participants’ point
of view, rehabilitation can be effective in increasing or supporting awareness
of deficits. However, participants were required to recall and reflect upon
their past experiences of rehabilitation. A further issue raised is whether individuals with awareness deficits and other cognitive deficits can comment
insightfully on their experiences. However, as noted by Paterson and ScottFindlay (2002), qualitative interviewing methods aim to capture the subjective accounts of reality for individuals despite their cognitive impairments.
Rather than relying on retrospective accounts, however, it may be beneficial
to seek participants’ perspectives of their experiences of therapy on a sessionby-session basis throughout rehabilitation. Seeking such timely and successive feedback may assist in the design and evaluation of awareness
interventions.

Research rationale and objective
The main objective of this case study was to explore how an individual
(CP) perceived and reacted to different components of an awareness intervention in the context of a return to work programme. To gain a sense of the
experiential dimension of rehabilitation we sought feedback concerning
CP’s perspectives of different therapy exercises throughout the 12-session
intervention.

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METHOD

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Research design
The present study employed case study methodology and use of multiple data
sources to understand the phenomenon in depth (Yin, 2003). These sources
included neuropsychological test findings, questionnaire data, field notes
from observations by the research clinician and data from ongoing interviews
with the participant about his experiences of the programme. CP was therefore a key informant in the research. According to Gilchrist and Williams
(1999), key informants are “individuals who possess special knowledge,
status, or communication skills, who are willing to share their knowledge
and skills with the researcher, and who have access to perspectives or observations denied the researcher through other means” (p. 73).

Participant background
At the age of 33 CP experienced a stroke related to thrombosis in 2000. Prior
to his injury CP had completed a university degree and worked in finance and
administration positions. At the time of his injury he was single and undertaking further study. CP experienced a right thalamic infarction as a result of
dissection of the right vertebral artery. He experienced a subsequent small
left pontine infarct two days after the initial stroke. The thrombosis was
treated with anti-coagulants.
Descriptive details of a neuropsychological assessment conducted nine
months after the stroke indicated that CP’s Verbal IQ was in the “high
average to superior” range for his age with particular strengths noted on
measures of immediate attention, abstract reasoning, arithmetic and general
knowledge. His Performance IQ was described as “significantly lower than
his Verbal IQ and relative to his age group”. General difficulties were
noted in the following areas: visuo-spatial construction, working memory,
motor speed, speed of information processing, divided attention, verbal learning and coping with distractions or interference, mental flexibility and ability
to monitor verbal responses. Visual memory abilities were at a lower level
than verbal memory abilities. CP’s pattern of deficits was noted to be
“most certainly a consequence of his strokes” and consistent with right thalamic damage. The neuropsychological report also documented dysarthria,
left-sided weakness, anosognosia, and emotional lability.
For several years after his injury CP worked as a volunteer in administration positions for charity organisations and received extensive return to
work assistance from a specialised vocational rehabilitation service. He
participated in work trials and applied for many positions in administration,
often attending job interviews, but was unsuccessful. A work training

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evaluation indicated that despite CP’s strong interpersonal skills, his speed
and accuracy on clerical tasks was impaired and he required constant supervision and checking of his work.
CP attempted to move out of home on a number of occasions with the
support of his family and rehabilitation case manager. However, he would
typically develop depression shortly after the move and return home to live
with his parents. Various stressors and disappointments (e.g., not obtaining
employment after a work trial or perceiving a lack of progress in his
return-to-work plans) appeared to trigger depressive symptoms such as low
mood, loss of motivation, lethargy and occasional suicidal ideation. In
2003 CP was prescribed antidepressant medication by his general practitioner
and later began seeing a private neuropsychologist for counselling in 2004.
The frequency of sessions varied from bi-weekly during periods of low
mood to one session every 2 – 3 months. This intermittent psychological
support continued throughout the present intervention. This treatment was
generally based on a cognitive-behavioural model, particularly at times of
crisis, and also included more general supportive psychotherapy.

Pre-intervention assessment findings
The findings of a neuropsychological review conducted just prior to the
present intervention are presented in Table 1. Overall, the findings were consistent with the earlier assessment concerning CP’s impairments in the areas
of processing speed, visual perception, visual memory and visual attention
(note: there was no evidence of unilateral neglect), although improvement
was evident on measures of working memory and auditory attention.
Reports from CP’s rehabilitation case manager of several years generally
indicated that he had persisting awareness deficits concerning the effects of
his stroke and unrealistic employment expectations. However, during
periods of depression he would display a pessimistic view of his employment
circumstances (i.e., stating that he may never return to work and that he was
not “job-ready”) and he occasionally expressed suicidal ideation. When CP’s
mood state improved he would restate unrealistic employment goals. His fluctuating mood state was observed at the start of one of the neuropsychological
testing sessions, when he burst into tears, quickly composed himself, and then
stated that he felt “brilliant”.
CP completed standardised measures of awareness of deficits and emotional status six months before the intervention and again at two weeks prior to
commencement. Six months prior to the intervention CP’s scores on the
Hospital Anxiety Depression Scale (HADS; Snaith & Zigmond, 1994) were
in the “mild” range for depression (10/21) and the “normal” range for
anxiety (5/21). However, he reported a “severe” level (16/20) of hopelessness on the Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, &

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TABLE 1
Neuropsychological assessment data at 5 years post-injury

Test

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NART-II
WAIS-III
VIQ
PIQ
FSIQ
Processing Speed
Working Memory
WMS-III
Auditory Immediate
Visual Immediate
Immediate Memory
Auditory Delayed
Visual Delayed
Auditory Recognition
General Memory
Memory
RCFT Immediate
Delayed
RAVLT-Total
Attention
Trails A
TEA – Map Search I/II
Elevator Counting (EC)
EC with Distraction
EC with Reversal
Visual Elevator
Executive Function
Trails B
RCFT Copy
FAS Test
Design Fluency
Haylings Brixton – A
B – Speed
B – Accuracy
Stroop Test: Color–Word
Zoo Map Test
Key Search Test
Tinker Toy Test

Raw score (Index or Standard
Score)

Percentile (description)

15 errors (estimated
FSIQ ¼ 112)

(High average)

71 (111)
31 (76)
102 (95)
8 (69)
37 (113)

77 (High average)
5 (Borderline)
37 (Average)
2 (Extremely low)
81 (High average)

18 (94)
7 (57)
25 (73)
17 (92)
10 (68)
12 (110)
39 (84)

34 (Average)
,1 (Extremely low)
4 (Borderline)
30 (Average)
2 (Extremely low)
75 (High average)
14 (Low average)

15 (T score ¼ 42)
10.5 (T score ¼ 36)
35

21 (Low average)
8 (Borderline-low)
7 (Borderline)

52 seconds, 0 errors
32/58 (6/3)

,1 (Extremely low)
,1–12 (Extremely low to low
average)
Normal
80-88 (High average)
57-69 (Average)
31-43 (Average)

7
10 (13)
8 (11)
9/3.7 (9)
100 seconds, 1 error
35
29 words, 0 errors
17 designs, 2 errors
0
70
3
40
1
3
5

,1 (Extremely low)
90 (High average)
15 (Low average)
.2 (Extremely low)
75 (High average)
10 (Low average)
75 (High average)
,2 (Extremely low)
9 (Borderline– low)
70 (Average)
15 (Low average)

NART-2 ¼ National Adult Reading Test – Second Edition; RAVLT ¼ Rey Auditory-Verbal
Learning Test; RCFT ¼ Rey Complex Figure Test; TEA ¼ Test of Everyday Attention; WAIS-III ¼
Wechsler Adult Intelligence Test–Third Edition; WMS-III ¼ Wechsler Memory Scale –Third
Edition. Source: Lezak, Howieson, and Loring (2004), Wilson, Alderman, Burgess, Emslie, and
Evans (1996).

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Trexler, 1974). On the Self-Awareness of Deficits Interview (Fleming et al.,
1996) CP scored 5/9, which reflected some acknowledgment of post-injury
changes (mainly activity restrictions such as driving) but suggested
minimal recognition of cognitive deficits and largely unrealistic goals (e.g.,
anticipating full-time work in his previous field of finance). Interestingly,
his goals were incongruent with his negative expectations and beliefs indicated on the BHS. On a measure of defensiveness and self-deception
(Marlowe-Crowne Social Desirability Scale; Crowne & Marlowe, 1960)
CP’s score (18/33) was in the normal range.
Two weeks prior to the intervention CP’s mood symptoms (HADS
Depression ¼ 8, Anxiety-1; BHS ¼ 18/20), awareness of deficits
(SADI ¼ 4/9) and defensiveness (15/33) were largely consistent with the
earlier assessment.

Opinion and rationale
The intervention was initially discussed with CP, his rehabilitation case
manager and CP’s parents. CP’s rehabilitation case manager identified
some concerns that due to CP’s “fragile” psychological state he might
become more distressed if he received feedback about his post-stroke deficits.
While this was an important consideration, CP’s frequent periods of
depression and high level of hopelessness suggested that he was aware of
negative circumstances following his stroke (e.g., lack of success in finding
work, inability to drive, loss of independence), but could not identify the
reasons for these limitations nor understand what he could do to improve
his situation. CP’s parents were keen to support an intervention that aimed
to facilitate his personal goals to live independently and achieve paid work.
CP was very motivated to commence the intervention and particularly
valued the idea of providing the therapist with feedback concerning each
therapy session.
A therapeutic intervention was designed to concurrently target the following: (a) development of awareness of deficits, (b) ability to self-monitor performance, (c) use of corrective or compensatory strategies, (d) self-efficacy
and emotional adjustment; and (e) realistic goals and expectations. The
awareness intervention was conducted independent of the long-term psychological support provided by the private neuropsychologist, although the
objectives and components of the intervention were discussed with this therapist. The self-awareness intervention was considered to be complementary to
the general therapeutic approach, in that both methods of intervention encouraged CP to identify evidence for both over and under-estimates of his
performance; however, the psychological support focused more on his interpersonal interactions and self-worth while the rehabilitation intervention
focused more on his functional competencies. Half way through the

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TABLE 2
A summary of the intervention components and therapeutic focus of each session

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Rehabilitation session

Therapeutic focus

Session 1
(a) Psychoeducation regarding the brain and
General knowledge of the brain and brain injury
effects of brain injury
(b) Specific questions about post-injury changes Self-knowledge: Awareness of deficits and their
and their implications
everyday impact
Session 2
(a) Self-ratings of personal strengths and
Self-perception of physical, cognitive and
limitations (ratings: High average, Average,
behavioural abilities
Low, Very low)
(b) Feedback using a graph of self-ratings and
Self-evaluation of the discrepancy between selfobjective performance indicators
ratings and CP’s cognitive performance and
(neuropsychological test results and relative’s
relative’s ratings
ratings)
Session 3 – Role reversal
(a) Therapist’s prediction of her own cognitive
(Task designed to increase CP’s understanding of
performance on tasks with feedback from CP
the function of self-predictions and feedback)
(b) CP’s prediction of his cognitive performance Self-prediction prior to cognitive performance
on a different set of tasks and feedback from
and self-evaluation of the accuracy of
the therapist
predictions
Session 4
Performance predictions on functional tasks (e.g., Self-prediction of functional performance on
paying rent, scheduling appointments,
future activities (anticipatory awareness)
attending a work training course)
Session 5
Adjustment counselling
Emotional support
Session 6
Participation in a cooking task with prompts to
Pre-task predictions (anticipatory awareness) and
self-monitor performance, followed by selfself-monitoring (on-line awareness) and
observation on video.
review of self-predictions
Session 7
Practice on the cooking task with an initial review Identification of goals for improving performance
of performance on video
and immediate practice of skills during cooking.
Session 8
Participation in a group therapy session with 5
Self-reflection on recovery and personal goals and
other individuals with ABI
sharing of experiences with peers
fBreak from the intervention for 2 weeks to receive more intensive support from the private
neuropsychologistg
Session 9
(a) A review of sessions to date
Exploring the impact of the intervention upon
self-perceptions.
(b) Preparation for work experience in a bookshop Performance predictions (anticipatory awareness)
and self-predictions of performance on a range
and planned use of compensatory strategies
of tasks
(Table continued)

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701

TABLE 2
Continued
Rehabilitation session

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Session 10
Work sampling in a bookstore: training from a
staff member on a range of tasks

Therapeutic focus

Self-monitoring performance and self-evaluations
according to prior predictions. Experience in
receiving immediate feedback on-the-job

Session 11
A follow-up session in the bookstore to assess the Independent self-monitoring (without therapist
effects of previous training
prompts), self-correction and self-appraisal of
performance
fA break of one month until CP obtained a work trialg
Session 12
Observation and application of self-monitoring
Independent self-monitoring (without therapist
procedures to a work environment (a large
prompts), self-correction and self-appraisal of
retail store) with a prospective employer and
performance
the job coach
a

Cognitive tasks included: line bisection, immediate recall of a number sequence, recall of a short
story, copying a design, and constructing an object (speed and accuracy).

intervention CP was linked with a disability employment service to commence the job search, job placement and on-the-job support process. The
latter sessions in the intervention were in part guided by the opportunities
that developed to observe and provide training to CP in various work settings.
An outline of the 12 sessions of the awareness intervention is provided in
Table 2 with a summary of the therapeutic focus of each session. These
therapy components are based upon the theoretical framework of Toglia
and Kirk (2000); the efficacy of which has been supported by empirical
research (see review by Fleming & Ownsworth, 2006).

Monitoring CP’s reactions and feedback
Based on the principles of key informant interviewing (see Gilchrist &
Williams, 1999), immediately after each therapy session an informal debriefing was conducted using a semi-structured interview format (10–15 minutes).
Given the importance of established rapport, timely questions and the
relevance of CP’s feedback in tailoring the intervention to his needs the interviews were conducted by the therapist at the site of the session, which
included CP’s home, work experience site and the group therapy setting.
General questions related to the content and process of the session and the
therapeutic relationship. These included: “How did you find today’s
session?”, “What, if anything, do you feel that you learnt?”, “Was there anything particularly helpful or unhelpful?”, and “How did today’s session
compare to previous sessions?” Specific questions inquired about particular

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aspects of the session. For example, “How did you feel when I gave you feedback that you had overestimated your performance on the memory task?”
Memory prompts were used as needed during the interview. The therapy
debriefing was audio taped and transcribed after each session. The therapist
used a mental status examination format (Trzepac & Baker, 1993) to structure
observations during the session. Observations were recorded as detailed low
inference field notes.

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Data analysis
The transcripts of the informal debriefing and field notes were analysed thematically with narrative data coded into categories. A researcher who was not
involved with the intervention or data collection process conducted this
analysis. The initial section of the results presents a description of CP’s reactions and feedback throughout the 12-session intervention with selected
illustrative quotes. The second section presents the major themes emerging
from the analysis of interview transcripts.

RESULTS
CP’s reactions and feedback throughout the intervention
Session 1(a) Psychoeducation about the brain and brain injury. CP
observed that this was “very interesting. . .I had never been educated about
different parts of the brain. . . . maybe you could tailor it more to the client
and their background”.
Session 1(b) Questions concerning the effects of CP’s injury. CP found it
difficult to answer specific questions about the effects of his injury and repeatedly stated that the therapist should ask his private neuropsychologist or rehabilitation case manager to obtain “an objective opinion”. When prompted to
consider the long-term effects of his stroke CP felt that acknowledging such
problems would mean he was “a second class citizen”. CP described this
exercise as neither helpful nor unhelpful but “somewhere in between.”
Session 2: Self-estimations of cognitive, physical and behavioural
abilities. CP found it more difficult to rate his cognitive abilities (e.g.,
memory for conversations, ability to plan) than his physical and behavioural
skills because he did not feel that there was a “benchmark” or “a standard”
against which he could compare himself. When he received feedback that
he rated his cognitive ability higher than his actual performance on the previous neuropsychological assessment he responded that it was an employer’s

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or a therapist’s responsibility to provide training for a person to improve. For
example, he felt that someone with visuo-spatial impairments could receive
training to become an air traffic controller or to learn to drive (“If a job
requires it, you can work on it”). Thus, he did not view impairments as
permanent nor a barrier to employment.
Session 3: Role reversal with predictions of cognitive ability and immediate
feedback. The therapist deliberately overestimated her performance on
some cognitive tasks to enable CP to provide feedback. He commented:
“Don’t worry, everyone can make that mistake but at least now you
know.” When the roles were reversed and CP predicted his performance he
received feedback that he had underestimated his skills in a particular area.
He stated: “Wow, that is really good to know. . ..it made me feel really
good that I was better at something than I thought.” After receiving feedback
that he had overestimated his memory for a short story he commented: “Well,
that is not as good. . ..at least I know for next time.” CP identified that receiving feedback immediately after performance is particularly important in a
work setting, as follows: “I think it’s important to get it [feedback] early
because you’ve got to know how you are measuring up against their standard. . .but it needs to be accurate feedback.”
Session 4: Self-prediction of functional performance on future
activities. CP predicted that many activities he had planned would go
well over the next few weeks but also identified some for which he was
less certain. He anticipated that his memory, visual attention and motor
co-ordination skills might influence the outcome on some activities. CP’s
evaluation of this session was positive: “It’s all about anticipation so that if
anything crops up you have a plan. Planning the next couple of weeks of
my life is just so important.”
Session 5: Adjustment counselling. CP became upset at the beginning of
this session as he described a situation that had arisen during the week. The
therapist focused the session on exploring these issues with him. CP felt concerned about people’s expectations of him and that he did not know what the
“benchmarks” were in a job. He identified that difficulty regulating his
emotions might be problematic for job-readiness and living independently.
CP explained: “Crying like this means that I am not normal, that I am still
a second-class citizen.” CP received psychological support from his private
neuropsychologist and stayed with his parents for a few days.
Session 6: Self-predictions and self-evaluation of functional
performance. After completing the cooking task CP said that he had felt
a bit nervous about being observed but liked the fact that “we were trying

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to make it more like a real life situation. . .like a work situation. . .and you are
not always able to plan for things on the job” . He felt that this activity added
to the previous sessions because: “Cooking is very hands on. . . . much more
useful. That’s another reason why we should do the work sampling. . . so
you can get confidence and know exactly what the feedback is.” CP
wanted to watch the video of his cooking session and repeat the same meal
during the next session to “Do it better. I think I could improve things and
make changes. . .yeah.”
Session 7: Practice on the cooking task. CP became distressed at the start
of this session while discussing his perceived lack of progress with return to
work plans. However, he was keen to commence the cooking task and identified several areas for improvement based upon the video self-observation. On
completing the activity he identified: “The video was good because it was
completely objective. So it wasn’t just a person’s opinion, it was what happened. And you could see that if there was something wrong you could fix
it.” When the therapist asked if there were other ways of obtaining feedback
CP commented: “I suppose you could ask your boss or job officer to watch
you and give you feedback.” After a pause he added: “And, just think
about what you did wrong and what you need to improve and how you can
do it faster.”
Session 8: Peer support and group therapy. Other group members
offered their encouragement when CP became upset while discussing his
work difficulties. CP seemed to take great interest in their perspectives.
After the session CP noted: “I didn’t realise that other people had been
depressed after their injury too. . .it was good to hear that they could get on
with their lives and get jobs and things.” He also identified a limitation of
the group session was that the suggestions were not specific to each
individual.
Sessions 9, 10 and 11: Self-prediction and self-evaluation of work
performance. In preparation for his work sampling in a bookshop CP
made predictions about his performance on a range of tasks. In relation to
one task he commented: “Actually, I think this could be a bit difficult
because that needs a bit of fine motor.” CP recognised that this prediction
proved correct during performance and asked for advice so that he could
adopt a strategy. During the debriefing CP identified: “It was really good
and useful to, sort of, get me into the mould of work after a lapse” and that
making predictions “helps because you know if you are going to find something easy or hard” .
During the second work sampling session CP predicted that he would take
several attempts to complete particular tasks without prompts. However, CP

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completed these tasks correctly without any prompts and spontaneously
applied strategies. He evaluated his performance as follows: “Well, I went
better than I expected. . .but I wanted to give myself some leeway – expecting
the worst and getting the best rather than expecting the best and getting the
worst I suppose you could say.” When the therapist raised the issue of job
readiness CP commented: “Well, I guess it’s something. Job readiness is
something that is good now because you’ve done a couple of tasks, even if
they’re simple tasks. . .so this programme is a confidence building process.”
Session 12: Observation at a work trial. This session focused on the
application of self-monitoring and feedback procedures in a prospective
work environment (a large retail store) with staff and the job development
officer. In the debriefing CP was asked to review the entire programme. He
identified: “It’s all about being more realistic isn’t it? You have to find out
what your strengths and downfalls are so that you can be realistic about the
type of work you want to do.” He additionally advised: “The comment I
would make is to try and make things as close to the workplace and reality
as possible.”
During the post-intervention assessment on the SADI (score: 2/9) CP
reported the following work goals: “Hopefully in six months time I’ll be
working 2– 3 days a week, 6 hours per day – maybe at [place of work
trial]. I’m not sure what will happen, but this is what I hope. I need to be realistic.” On self-report measures of emotional status CP was in the “mild”
range for anxiety and hopelessness and the “normal” range for depression.
Three weeks later CP was offered part-time paid work as a retail assistant
(3 days per week, 5 hours per week) and had maintained this position at
follow-ups conducted at 3, 6 and 9 months post-intervention.

Major themes
Understanding benchmarks and the value of feedback. The main theme
that pervaded the CP’s responses over the 12 sessions referred to the
concept of “benchmarks”. At times he used this word and at other times he
used different words and phrases, such as “yardstick”, “standards” and
“knowing what’s expected”, to convey this idea, depending on the focus of
the session. His answers, particularly during the early sessions that involved
direct questioning about his post-injury impairments, seemed to raise the
question of who should evaluate his skills – him or someone else? CP
often deferred to, or sought the opinions of others he considered to have
more expertise. The issue of benchmarks and social standards appeared to
place considerable pressure on CP, which affected his self-confidence and
perception of work readiness.

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In subsequent sessions throughout the programme, which entailed situation-specific feedback and skills practice, CP seemed to learn that he
could better understand standards of performance by seeking feedback
from various sources and that this needed to occur early or immediately
after task performance for him to personally benefit. He discovered that
while feedback could be obtained from therapists, employers and job development officers, he could also gain feedback from self-observations (e.g., on
videotape) or by reflecting on his own performance.
Learning through practical experience. The rehabilitation intervention
utilised a range of different approaches to increasing CP’s awareness of his
skills and impairments. Both therapist observations and CP’s comments
demonstrated that he preferred and benefited most from learning through
practical experience. In particular, following the cooking task, CP gave his
evaluation that the practical session had been more helpful than the earlier
ones because it was “hands on”. However, he made the point that other sessions were useful when they involved making predictions about “real life”.
Individualising therapy. Throughout the 12 sessions, CP continually
referred to the importance of individualising the task or exercise. In the
group session he perceived a limitation that the suggestions were not specific
to an individual. In CP’s discussions about the sessions, he often made reference to his family background. As both of CP’s parents worked in the scientific field and he previously worked in finance, he frequently made comments
about the “scientific” perspective or “objectivity” being important to him.
However, this reference was always placed in the context of understanding
that the needs and experiences of others might be different to his. His
answers to various questions related to his major goal of work, particularly
in the field in which he was receiving training.

DISCUSSION
The present study investigated a participant’s perspectives throughout a
12-week intervention designed to enhance self-awareness and self-regulation
skills. His perceptions indicated that the therapy sessions promoted greater
understanding of benchmarks and the value of feedback, and enabled learning
through practical experience. Individualising or tailoring rehabilitation
according to his background and personal goals also enhanced this process.
CP’s emotional reactions to the intervention were closely monitored and
managed by the project clinician in collaboration with his private neuropsychologist and supportive family. Of note, CP described the programme as “a
confidence building process”, thus reinforcing that awareness interventions

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can enhance emotional adjustment (O’Callaghan et al., 2006; Ownsworth,
2005). CP’s awareness deficits and reactions can be considered in a biopsychosocial context.
In terms of neurocognitive factors, CP displayed marked impairments in
visual perception, speed of information processing, psycho-motor speed,
visual attention and visual memory, consistent with right hemisphere
damage and thalamic strokes (Kumral, Kocaer, Ertübey, & Kumral, 1995;
Myers, 1999). Models of awareness deficits (see McGlynn & Schachter,
1989; Morris & Hannesdottir, 2004) propose that conscious experience of
post-injury changes requires an interaction between relevant functional
domains (e.g., sensory, perceptual, motor and cognitive functions), comparator mechanisms within the central executive system to detect change, and the
conscious or metacognitive awareness system. This feedback system relies
upon updates regarding the experience of success and failure on tasks thus
contributing to an individual’s self-knowledge of personal abilities and
impairment (Morris & Hannesdottir, 2004). This might occur from feedback
from other people and structured opportunities to self-evaluate one’s performance. Awareness deficits can arise from a disruption at various stages of processing within this integrated network. While the components of this network
have not been specifically localised, thalamic lesions are found to produce
diverse impairments in sensory, perceptual, motor and cognitive processes
(Kumral et al., 1995), while disturbances in mood and self-awareness
have previously been observed after right thalamic lesions (Liebson, 2000).
Direct damage to the thalamus and/or disruption of connecting pathways
to various regions of the cortex (e.g., fronto-thalamic pathways) may
have contributed to CP’s deficits in awareness and emotional regulation
(Bogousslavsky, 1994).
Interestingly, once CP learnt about performance expectations in relevant
situations, with training and practice on specific activities, he learnt to selfmonitor his behaviour, identify errors and correct these during performance.
CP did not display global executive dysfunction on testing, and thus his
capacity to adopt metacognitive strategies most likely relied upon some
intact higher-order cognitive abilities. CP’s relative strengths in language
expression enabled him to articulate the reason why he found it difficult to
judge his own abilities, which related to a failure to understand benchmarks
for performance, both in therapy and in work settings.
In terms of psychosocial factors influencing CP’s awareness of deficits, he
indicated that he preferred to receive feedback on his performance on practical tasks rather than direct questioning about his abilities. The concern about
appearing a “second class citizen” emerged when CP was feeling uncertain of
his abilities and suggested more deep-seated issues concerning acceptance of
his disability and social stigma. Similar grief and loss issues have previously
been observed following ABI (see O’Callaghan et al., 2006; Ownsworth,

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2005; Ruddle & Coetzer, 2005). Ideally, these maladaptive beliefs would be
explored and addressed through individual or group psychotherapy within a
more holistic rehabilitation context. Overall, CP’s motivation during the
intervention was high, however, when he experienced heightened emotional
distress his support needs were accommodated in the programme by breaks or
modifying sessions. Engaging in practical activities such as cooking was
found to improve CP’s mood state and shift the focus of his self-appraisal
from negative thoughts regarding his job readiness to personal achievement
in other activities. CP appeared to benefit considerably from psychological
support from the private neuropsychologist, particularly to cope with reactive
depression in relation to ongoing stressors and life events.
The present study suggested that by developing more realistic expectations
and modified goals CP was able to participate more actively in the job search
and placement process. Ideally, this attitudinal and behavioural shift occurs
during the pre-vocational rehabilitation stage prior to seeking employment
(Ben-Yishay et al., 1987). It appears that some individuals may need to
experience a lack of success with goals in order to develop a greater understanding of the impact of their deficits. However, such negative experiences
may be overwhelming and lead to the development of heightened psychological distress (Langer & Padrone, 1992; Ownsworth & Oei, 1998). In general, a
graduated return to work process with work sampling and early supportive
feedback is recommended to prevent long-term psychological dysfunction.

Clinical implications
The present therapy intervention was designed to provide structured opportunities for CP to learn about the effects of his stroke and develop self-regulatory strategies (Toglia & Kirk, 2000). These experiences commenced with
general exercises that are commonly used in brain injury awareness interventions, such as psychoeducation, feedback on assessment results, and a
strengths and limitations self-assessment (see Fleming & Ownsworth,
2006; Toglia & Kirk, 2000), but subsequently the intervention became
increasingly tailored according to CP’s goals, incorporating participation
on familiar and meaningful activities that CP requested feedback and
support with. The approach is consistent with the “client partnership”
approach advocated by McKenna and Tooth (2006), and other clientcentred practices adopted in brain injury rehabilitation (see Wilson et al.,
2000; Wressle, Eeg-Olofsson, Marcussen, & Henriksson, 2002).
However, the present intervention additionally demonstrated the value of
establishing a bi-directional feedback process between the client and therapist
at the commencement of an intervention, and structuring time for such communication within each therapy session. Therefore, while the focus of many
sessions involved the therapist providing feedback to CP regarding his

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performance on tasks, CP additionally provided consistent feedback to the
therapist regarding his experiences and the value of particular exercises
throughout the programme (i.e., during the therapy debriefing). This mutual
approach is likely to contribute to the therapeutic alliance, which previous
research suggests is related to awareness of deficits (Schönberger, Humle, &
Teasdale, 2006). The present study supports the value of therapy debriefing,
particularly in the context of awareness interventions, to monitor individuals’
perceptions and reactions to different components and assist in processing the
meaning of these experiences.

Methodological considerations
The present case study was designed to identify a participant’s perspective of
his experiences throughout an intervention designed to improve self-awareness and self-regulation. Clearly, however, the findings regarding this
process for one individual with particular clinical characteristics (i.e., persisting awareness deficits, fluctuating emotional state, and high motivation for
treatment) cannot be broadly generalised to other individuals with ABI.
The comprehensive data provided in relation to CP’s neuropsychological
and psychological functioning may assist in determining the relevance of
the findings to other clinical contexts. Additionally, the detailed description
of the intervention components may support the application of therapy techniques, in this relatively sparse area of rehabilitation practice.
While the present study was primarily concerned with CP’s perspective of
the therapeutic process, rather than evaluating an awareness intervention or
return to work programme, it is important to acknowledge that CP was receiving concurrent psychological support from a private neuropsychologist and
the disability employment service. Therefore, although feedback concerning
CP’s experiences was sought immediately after each session of the awareness
intervention, the outcomes of the intervention need to be considered in this
broader support context. The treating therapist in this study conducted the
therapy debriefings with CP to obtain timely feedback and assist in the
design of subsequent sessions. It is important to acknowledge, however,
that CP’s responses may have differed if the interview had been conducted
by a professional independent of the intervention.
Given the exploratory nature of this study, further research into participants’ perspectives of participating in rehabilitation is needed to assist in
the design and evaluation of awareness interventions. By progressively monitoring clients’ reactions to therapy sessions it may be possible to identify
common experiences regarding the value of different exercises. Combined
with an evaluation of rehabilitation efficacy (i.e., pre- and post-intervention
outcomes), this type of investigation has the potential to identify not only
who benefits from different interventions but also participants’ own

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evaluation of their experiences and therapy outcome. Although there are
pragmatic and methodological issues to consider when interviewing individuals with awareness deficits and cognitive impairment, due to their potential
difficulty in reliably recalling and articulating experiences (see review by
Paterson & Scott-Findlay, 2002), such methods can provide a valuable
insight into personal accounts of rehabilitation which to date have largely
been overlooked in the literature.
In conclusion, the findings of the present study suggested that from CP’s
perspective the awareness intervention promoted greater understanding of
benchmarks and the value of feedback, and enabled learning through practical
experience. The importance of tailoring rehabilitation according to his background and personal goals was also recognised. Future investigations of
participants’ perspectives in rehabilitation may assist in understanding how
clients perceive the value of different therapy components, thus assisting in
the design of interventions that are meaningful to individuals with awareness
deficits.

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