Do you remember the New Year’s resolutions you made this year? Have you ever succeeded? Chances are that you have not, this is why.

There are three elements that are important for us to be able to change our behavior. First, there must be suffering. This sounds harsh but it means that you really feel the need to change. In a way, you have to be suffering from the behavior you are showing now. Part of suffering also means that you need to know there are alternatives. Second, you need to have the discipline to suppress your own habits and resist social pressure. Third, you need to know that the problem and, more importantly, the solution lies with you. You are the one that needs to change. If one of these elements are missing, you most likely don't change your behavior.

You can imagine that if someone does not see a problem, they do not want to change. And why would they? The story quite changes when we look at it from the context of a rehabilitation center for people with brain injury.

Some people with a brain injury have trouble recognizing that, or how, they have changed. This is called impaired self-awareness. This often leads to overconfidence. People might think they can go back to their full time job while this is clearly still too much for them. It can even get dangerous when, for example, people think they are ready to drive a car but on the highway if something unexpected happens they might get overstimulated and freeze or panic. Typical things patients with impaired self-awareness say are “I don’t have a problem”, “yes, but…” and then insert an external reason, or they might not want to talk about it at all.

The patient here clearly misses at least one of the three elements for behavioral change. Namely, they do not feel that they need to change or that the solution lies within them. For significant others and therapists this can be very frustrating because they might see things are not going well and want to help but the person is not listening to them. This, of course, is a recipe for disaster and it is easy to get stuck in a tug-of-war.

Why do people have impaired self-awareness?

We do not know exactly how this impaired self-awareness occurs but there are different possible pathways that can lead to this phenomenon. After a brain injury, people can have difficulties in a range of functions. We can see self-awareness as such a brain function. It seems like a network including the anterior cingulate cortex, posterior cingulate cortex, and frontal lobe is involved in self-awareness. A brain injury could damage brain areas or connections in this network. This results to impaired self-awareness. A second pathway is that people need to relearn their strengths and weaknesses after a brain injury. This takes time because people need to put themselves in all sorts of situations to know whether they can do it or not. An incorrect ‘recalibration’ can also be seen as impaired self-awareness in the clinic. A third pathway is more psychological. A brain injury often is paired with a traumatic event. It is very normal for people to show psychological reactions to such big life events. Some people have denial as a coping mechanism. This means they cannot acknowledge the consequences of their injury right away.

The question remains what the best way is to improve someone’s self-awareness. Different therapies seem to improve self-awareness but it remains unclear which is best. Hopefully this will be discovered in future research since this is very relevant in the rehabilitation care after a brain injury, but probably also for people without brain injuries while making their New Year’s resolutions on New Year ’s Eve.

Author: Anneke Terneusen