‘I’m Fine. I Don’t Need Help With My Speech.’ Clients who are unaware of their deficits may need special care. Here are some tips for treatment. On the Pulse
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On the Pulse  |   February 01, 2017
‘I’m Fine. I Don’t Need Help With My Speech.’
Author Notes
  • Margaret Lehman Blake, PhD, CCC-SLP, is associate professor in the Department of Communication Sciences and Disorders at the University of Houston. Her primary research interest is communication disorders related to right-hemisphere brain damage and mild traumatic brain injury. mtblake@uh.edu
    Margaret Lehman Blake, PhD, CCC-SLP, is associate professor in the Department of Communication Sciences and Disorders at the University of Houston. Her primary research interest is communication disorders related to right-hemisphere brain damage and mild traumatic brain injury. mtblake@uh.edu×
Article Information
Language Disorders / Attention, Memory & Executive Functions / Traumatic Brain Injury / On the Pulse
On the Pulse   |   February 01, 2017
‘I’m Fine. I Don’t Need Help With My Speech.’
The ASHA Leader, February 2017, Vol. 22, 42-43. doi:10.1044/leader.OTP.22022017.42
The ASHA Leader, February 2017, Vol. 22, 42-43. doi:10.1044/leader.OTP.22022017.42
What can you do when your patient is not aware of her communication deficits?
Reduced awareness of deficits—anosognosia—is a complex disorder most commonly related to right-side brain damage. One reason it is so complex is that it is not an all-or-none disorder.
  • Patients may be aware of some deficits but not others. They are more likely to be aware of concrete deficits, such as hemiparesis, than abstract deficits, like cognitive or communication disorders.

  • Some patients have implicit—but not explicit—awareness. For example, they can’t verbally tell you they have hemiparesis, but they never attempt to get out of bed on their own.

  • Some patients can report they have a deficit without being fully aware of the consequences. A client may report that she can’t move her left arm, for example, but then says she is going to get back to quilting when she gets home.

  • Some patients become aware of a deficit as they begin to experience failure, but can’t maintain this awareness to anticipate failure in a similar situation.

Anosognosia, not surprisingly, is linked to poorer participation in rehabilitation and poorer outcomes. Clients with anosognosia tend to have lower functional status, are less independent in activities of daily living, and are less likely to return to independent living or gainful employment.

A client may report that she can’t move her left arm, but then says she is going to get back to quilting when she gets home.

First … why?
The plan of treatment begins with trying to identify why the patient is unaware of deficits.
  • If the patient has not been told about a disorder or not had the chance to experience the consequences, you can provide an explanation tailored to the client’s specific problems. With this information, patients may be able to monitor their behavior and recognize the problems. You also can provide an opportunity for patients in a structured living environment—where there is limited opportunity for independent action or decision-making—to experience consequences of their cognitive deficit.

  • Is the lack of awareness related to another cognitive deficit, such as memory or abstract reasoning? Assess the patient’s cognitive processes or consult neuropsychology reports, and use cognitive rehabilitation techniques to address those deficits.

  • Is it part of a psychological response to the brain injury? Observe the client’s responses to feedback. If she gets defensive or angry, attributes the failure to someone or something else, and shows agitation, refer the client to neuropsychology.

If you can rule out these causes, the anosognosia is likely due to damage to the regions of the brain responsible for self and performance awareness, and treatment should address the awareness directly.

Brain injury may limit how easily a client can adapt behavior in response to feedback.

Strategies
The evidence is not strong, but providing education, feedback (verbal or visual) and safe environments in which to experience failure related to a deficit have been used with some success. Here are some suggestions for a hypothetical client with reduced awareness of his verbose, tangential, disorganized discourse and attention deficits that affect comprehension.
Experiential exercises. When using this strategy, remember that brain injury may limit how easily a client can adapt behavior in response to feedback.
  • Give the client a series of directions, and identify which were omitted or performed incorrectly due to lapses in sustained attention.

  • Ask the client to retell the Cinderella story within a limited time frame. Identify tangents and disorganization.

  • Use the performance data to discuss the problems and develop strategies to address them.

Self-regulation strategies. First, ask the client to predict how well he will perform before starting a task.
  • “I’d like you to describe the last vacation you took. I’m going to be counting how many times you go off topic. How many times do you think that will be?”

  • “I’d like you to describe the last vacation you took, in no more than three minutes. I’ll be timing you. How many minutes/seconds do you think you will be over the limit?”

During the task, have the client monitor his performance using agreed-upon cues. Some suggestions include:
  • Clinician provides visual cues for tangents or time points (for example, at the one-, two- and three-minute marks).

  • Client stops and restarts when a tangent is recognized.

  • Client uses a timer to monitor time and improve pacing.

After the task is complete, compare the client’s predictions with performance. Review what went right and wrong, and evaluate whether the monitoring strategies worked. Use the information to modify the strategies.
Strategies to encourage participation that don’t require the patient’s explicit, verbal awareness.
  • Explain that you are going to work on techniques to improve communication that work for all people (regardless of whether they have deficits).

  • Educate family members on how to observe improvements in behavior, even if the client cannot verbally state awareness.

Anosognosia can be difficult and frustrating, especially for caregivers and clinicians. As you work with patients and caregivers, avoid using the label “denial of deficit.” Denial implies that the client is aware of—but does not want to admit—the problem. In fact, the client is unaware of the difficulties, but not actively denying them. Using more appropriate terminology can help avoid misunderstandings and frustration for the client and family members.
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February 2017
Volume 22, Issue 2