The Role of Self- Awareness in the Use of Strategy Training. Jessica Kersey, MOT, OTR/L, CBIS

Transcription

1 The Role of Self- Awareness in the Use of Strategy Training Jessica Kersey, MOT, OTR/L, CBIS

2 Objectives 1. Understand the implications of self-awareness impairments 2. Identify the active ingredients of strategy training 3. Understand the effect of self-awareness impairments on participation in intervention

3 Self-Awareness Anticipatory Awareness Emerging Awareness Intellectual Awareness (Skidmore, et al., 2011; Skidmore, et al., 2016)

4 Comprehensive Dynamic Interactional Model Metacognitive Knowledge Online Awareness Anticipatory Awareness Influences: Domain Depth of Awareness Knowledge Self- Knowledge Task Experience Self-Monitoring Self-Evaluation Ability Emotions Fatigue Motivation Task Difficulty Meaningfulness Value Cultural Context Responses to Feedback

5 Influence of Self-Awareness Impaired self-awareness is common after ABI Leads to poorer outcomes: Less engagement in rehabilitation Less use of compensatory strategies Low rates of independent living High family stress Worse vocational and community outcomes

6 Self-Awareness Can people with impaired self-awareness benefit from therapy?

7 Assessment of Self-Awareness Clinician-reported assessments Family-reported assessments Discrepancy scores

8 Intervention No interventions cause a large improvement in self-awareness Meta-cognitive approaches (like strategy training!) show the most promise Explicit strategy use Structured problem-solving approach Functional context Promote self-regulation

9 Strategy Training Top-down, metacognitive intervention Focus is on training the skill of self-evaluation and problemsolving that can be applied to a variety of goals, rather than training one specific task. Instead of training individual tasks, we can give our clients a strategy to apply to any goal or problem they identify by training our clients to think like therapists!

10 Strategy Training Self- Selected Goals Global Strategy Training Self- Evaluation Guided Discovery Generalization and Transfer

11 Global Strategy Use of Goal-Plan-Do-Check strategy as a method for structured selfassessment and problem-solving. Goal: Should be an activity-based, clear and achievable goal Plan: How will you achieve the goal? Should detail what, how, when, with what/whom, materials needed, anticipated challenges Do: Try out the plan Check: What worked and what didn t work? What modifications are needed so the plan will be more successful next time? Global Strategy Training

12 Self-Selected Goals Strategy training is all about putting the client in the driver s seat, beginning with goal-setting. Goals should be self-selected and occupation-based. Benefits: self-selected goals lead to better rehabilitation outcomes and better client engagement (Hunt et. al., 2015). Activity-based goals will anchor the session around a functional task. Enables the individual to practice applying the strategy to a real-life activity. Self- Selected Goals

13 Self-Evaluation Self-evaluation is incorporated into every step of the strategy: Goal: clients should be encouraged to break down goal based on current level of functioning Plan: clients should be guided to consider current level of performance and barriers Do: guiding cues should facilitate in-the-moment evaluation of performance Check: process relies heavily on evaluation of performance and identification of needed adjustments to plan for success in future attempts Self- Evaluation

14 Guided Discovery

15 Generalization Clients should generate alternate applications for identified strategies or solutions. Encourage the use of identified strategies in other similar (or not so similar) activities.

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18 Why Use Strategy Training? Evidence supporting strategy training: Reduces disability (Skidmore, 2017) Improves goal achievement (Dawson, 2009; Dawson, 2013; Dawson, 2014) May improve self-awareness (Toglia, 2011) May improve generalization of skills (Toglia, 2010) Reduces apathy (Skidmore, 2015) Improves executive function (Skidmore, 2015)

19 Research Questions 1. Does self-awareness improve over time? 2. Can adults with impaired self-awareness following stroke benefit from strategy training as much as those without impaired selfawareness? 3. Does strategy training improve self-awareness more than a control intervention following acute stroke?

20 Self-Awareness of Deficits Interview Self-awareness improves Self-Awareness by Time after Stroke Baseline Month 3 Month 6

21 Clients with impaired self-awareness can benefit from strategy training

22 Strategy training improves strategy behavior

23 Clinical Implications Can use the results to: Justify ongoing rehabilitation for patients with selfawareness impairments Educate families about prognosis for functional recovery Determine most appropriate intervention

24 References 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: Kersey, J., Juengst, S. B., & Skidmore, E. R. (in press). Self-awareness may or may not improve over time. American Journal of Occupational Therapy Richardson, C., McKay, A., & Ponsford, J. L. (2014). The trajectory of awareness across the first year after traumatic brain injury: The role of biopsychological factors. Brain Injury, 28(13-14), Richardson, M., McKay, A., & Ponsford, J. L. (2015). Factors influencing self-awareness following traumatic brain injury. Journal of Head Trauma Rehabilitation, 30(2), E43-E54. Skidmore, E. R., Butters, M. A., Whyte, E. M., Shen, J. & Terhorst, L. (2017). Guided training relative to direct skill training for individuals with cognitive impairments after stroke: A pilot randomized trial. Archives of Physical Medicine and Rehabilitation, 98, Skidmore, E. R., Swafford, M., Juengst, S. B., & Terhorst, L. (2018). Self-awareness and recovery of independence with strategy training. American Journal of Occupational Therapy, 72(1). Toglia, J., & Kirk, U. (2000). Understanding awareness deficits following brain injury. NeuroRehabilitation, 15,