How to motivate clients who have insight impairments

… (and minimise the impact on rehab)

 By Rachel Cotter, Clinical Psychologist

In this guest blog post, we asked Rachel to share some key methods she uses to engage clients who have decreased insight and decreased motivation in their rehabilitation program.

 It is common for clients with traumatic brain injury to lack insight into their injury. This can range from a total lack of insight, to recognising physical but not cognitive or behavioural/psychological difficulties. For clients, decreased insight can lead to two scenarios: overestimation of their abilities or underestimation of their abilities.

Clients with decreased insight often have difficulty engaging fully in their rehab program. If you don’t think you have any deficits, why would you try and mitigate them? It is useful to remember that insight tends to improve during the first two years post brain injury. But this can be a double-edged sword. As insight develops, clients become aware of how different they are now, versus before their injury. Whilst this helps them to recognise the need to use strategies, it can also result in a client feeling helpless or useless, and thus reduce their willingness to engage in rehab.

For every client you work with, it’s important to take a holistic view of them and their situation when considering how much insight they may have to their injury. This means considering biological or health factors (such as illness, medication side effects, gender), psychological or mental factors (such as denial, depression, anxiety) and social or environmental factors (such as their social supports, cultural background, socio-economic status) all at once. In health jargon, this is known as the ‘biopsychosocial’ model and it’s best explained in this diagram.

Remember, each person is different. Consider how your client might respond before trying these suggestions below.

Help your clients develop insight

Clients who lack insight may have difficulty in recognising deficits or difficulties, and understanding the functional implications of these deficits. Setting realistic goals can help.

• Help your client identify barriers preventing them from engaging in the life they want; such as with people and in activities important to them. This can help identify any insight difficulties and allow a client to begin to explore building insight. For example, ‘You really value time with your family but you continue to have difficulty being with them without snapping. What do you think is making this hard for you?’

TIP: Ask the family, therapy team and other supports to help identify barriers so you can prompt the client.

• Develop rating scales with your client. Develop a baseline (to help with insight building) and progress (to help with motivation). Some clients have partial insight into difficulties (for example, fatigue) but may not be aware of the extent of this. Self-rating can really help – for example, try measuring cognitive fatigue out of 10 at different times of the day (am/midday/pm).
• Some people need to experience failure. As a therapist, this can be hard to allow to happen. But letting someone fail does not mean we wipe our hands and walk away. It means allowing natural consequences in real life and being ready to support the client after the fact. Some lessons are learnt the hard way.

TIP: When you are highlighting an area of difficulty for a client in context, use a calm, non-judgemental tone and language.

Align your goals to client values

Look at meaningful activities or domains with your client. What do they value? This can help provide a good base for engagement and help the person to develop goals they are motivated to achieve.

• Utilise motivational interviewing

• Focus on working with your client at the stage they are at. Don’t simply tell them to do something. For example, ‘I know it’s really important to you to remember information. I know you used to remember everything independently. Why don’t we see how you go with remembering your anger management strategies? If you have difficulty remembering them we’ll look at ways to remind yourself next time’.

• Write down how your therapy goals fit with your client’s values (perhaps in table format). You, your client’s family and team can return to these to remind your client of the reason why they agreed to give the strategies a go and to keep things in front of mind. Writing down goals also helps everyone be specific in the language they use to reinforce goals, and can help with consistency.

Use a whole team based approach

Work towards the whole therapy and support team being on the same page about therapy programs.

• Reinforcing each other’s strategies and approaches can help a client understand why strategies are being recommended and when to use them.
• It’s important to remember, even without insight into deficits, behavioural gains can be made without conscious awareness by using techniques such as task specific learning and habit formation. Team based reinforcement of strategies and consistent practice are key.
• Your client’s family and team can jointly decide on key areas of impairment to highlight and focus on with your client.

Education and awareness 

Education around common difficulties and ways to mediate these in a general sense, before building in person-specific deficits and strategies, can normalise the experience for a client and decrease a sense of hopelessness.

This PDF from the Queensland Department of Health is a good handout to help clients and their family understand insight impairment.

Is this the best time to be involved?

If your client really can’t see any value in your involvement, is it really the right time for therapy? Sometimes people just aren’t ready to engage in therapy. Perhaps they feel they are living their values already. It is possible, even though they may demonstrate rehabilitation potential, they don’t really want the goal. It’s okay to consider that your intervention may be better at another time.

Other resources:

If you want to go deeper in your understanding of reasons why insight is impaired in traumatic brain injury, and strategies to improve it, try this:

https://www.neurorestorative.com/assets/sites/7/NeuroInstitute_October1.pdf