Editorial

The importance of consideration of self and identity in neuropsychological rehabilitation following brain injury has historically been the preserve of the holistic approach (Ben-Yishay et al., 1985). However, there has been a recent growth of interest in the topic in three broad areas. Firstly, the development of the field of social neuroscience has brought functional neuroimaging and processes pertinent to self-awareness and systems of self-representation together. Secondly, critiques of the cognitive-behavioural model of emotional disorders in the early 1990s led to the development of more highly specified and rigorous theoretical models of cognition and emotion which include representation and processing of self-relevant information. Thirdly, there has been a growth in the extension of post-modern thinking to clinical psychology generally and neuropsychological rehabilitation particularly. This social-constructionist turn emphasises subjectivity, language, social processes and the importance of understanding individuals as actively constructing meaning in the context of interactions with others.

This special issue sets out to present examples of work drawn from these three areas that is of particular relevance to the development of understanding of the self and identity in rehabilitation. In the foreword to this Special Issue, Yehuda Ben-Yishay lays out the inception and development of a model for the integration of “ego-identity” change into the process of rehabilitation. This provides a historical and conceptual context for the papers that follow, which have been divided into three sections: conceptual and theoretical issues, research studies, and clinical interventions and service provision.

THEORETICAL AND CONCEPTUAL ISSUES

Wilson, Kopelman, and Kapur review their previous account of post-encephalitic patient CW's “denial of past consciousness” as a delusion in the context of a recent neurological model of consciousness and self. The potential applicability of this neurological account of self, incorporating a conceptualisation of systems of self-representation, self-regulation, memory and awareness, alongside the hypothesised neurological substrate for these processes, is highlighted, alongside other hypotheses for CW's denial of past consciousness.

Fotopoulou provides a contemporary account of confabulation which draws attention to the role of motivation as well as neuro-cognitive factors, contending that the self-related positive biases inherent in these false memories support self-enhancement and self-coherence. Fotopoulou suggests that understanding the identity formation function served by confabulations, in addition to underlying neuro-cognitive mechanisms, may lead to more successful clinical management and rehabilitation outcomes. Intriguing case material is used to illustrate the implications of a motivational approach in rehabilitation of confabulation.

Yeates, Gracey, and Collicutt-McGrath offer a social constructionist review of the use of the term “personality change” in brain injury rehabilitation. A biopsychosocial framework is employed to offer alternative accounts of what might lead to judgement or experience of “personality change”. Clinical implications drawn from this highlight the need for sensitivity to the self-protective function an individual's language and behaviour may serve, and the need for integrated interventions that tackle the social contextual, neuro-cognitive, and self-representational systems that are implicated.

INVESTIGATIONS INTO SELF AND IDENTITY

Naylor and Clare investigate correlates of identity in their empirical study of the relationships between self-concept, awareness and autobiographical memory in early-stage dementia. Participants with a more positive and definite sense of self were found to display poorer awareness of their memory function and a greater impairment of autobiographical memory during the mid-life period. Consistent with the positions proposed by Fotopoulou and Yeates et al., these findings are interpreted using a biopsychosocial framework, whereby impaired awareness is proposed to have a protective function, namely, to maintain prior sense of self in the face of progressive functional decline.

Relationships between self-awareness, self-concept and cognitive function are also explored by Cooper-Evans and colleagues. This investigation of self-esteem and self-concept confirms that sense of self is negatively impacted by brain injury. In their long-term brain injury sample, self-esteem was found to be stable over a two-week interval. A higher level of self-esteem was related to reduced self-awareness and poorer cognitive function. Consistent with Gracey et al., the authors emphasise the need for subjective experiences to be a central focus in rehabilitation.

Using a group-based personal construct approach, Gracey et al. elicited bipolar constructs of self through structured small group discussions in a holistic rehabilitation setting. A key finding that emerged from the thematic analysis is that sense of self following acquired brain injury is primarily construed through subjective experiences associated with social and practical activities, thus highlighting how “meaning” and “doing” (in both tasks and social interactions) are intrinsically linked in reconstructing identity.

Extending the contextual dimension further, Cloute, Mitchell, and Yates take a social constructionist approach to understanding identity after traumatic brain injury (TBI) as experienced and constructed in the context of social interactions. A qualitative discourse analysis of interviews with participants with TBI and a significant other is presented. The authors find that people with brain injury can often be positioned as relatively passive in the context of a medical discourse about their injury, and may experience abandonment secondary to dependence on specialist services. A further theme of “progression and productivity” was also identified. The authors conclude that families require ongoing community support from brain injury services, and that such support needs to recognise the narratives and discourses used by clinicians, family members and the individual with TBI and “empower individuals with disabilities towards role engagement and participation in the community”.

The social nature of identity is further emphasised in the study by Haslam et al. who look at social group membership after stroke. Since social identity theory suggests that participation in social contexts is the means by which we realise our identities, they hypothesise that social group membership may be related to well-being after stroke. They apply a new measure, the Exeter Identity Transitions Scale, and their findings suggest that those with membership of multiple social groups prior to stroke that are also maintained post-stroke rated higher levels of well-being.

CLINICAL INTERVENTIONS AND SERVICE PROVISION

With a similar focus to that of Naylor and Clare on both self-awareness and identity, Ownsworth, Turpin, Andrew, and Fleming describe the process of intervention with their patient CP who had poor self-awareness of deficits following thalamic stroke. They present a qualitative analysis of CP's rehabilitation designed to tackle metacognitive skills in a structured manner. The themes identified from interview with CP suggest that structured feedback in relation to tasks set in rehabilitation, in addition to allowing CP to “learn from experience” while having rehabilitation goals individually tailored, were significant to CP. The authors conclude that restructuring of self-knowledge may occur in rehabilitation through “a bi-directional feedback process between the client and therapist” rather than one way feedback to the client about deficits from the clinician.

This emphasis of a collaborative approach that includes a specific focus on identity by linking meaning, goals and tasks is also described and advocated by Ylvisaker, McPherson, Kayes, and Pellett. In this two-part paper, the authors discuss identity in the rehabilitation process following TBI drawing upon cognitive models of self-representation and goal-directed behaviour. First they outline the theoretical background to a clinical approach called “metaphoric identity mapping” aimed at integrating identity (and related motivational states) into goal setting and restructuring of self-knowledge in rehabilitation. The second part of the paper presents qualitative data from a pilot study of a related goal setting technique called “identity-oriented goal setting (IOG)”. The qualitative analysis identified responses of both clients and clinicians emphasising the acceptability of this approach to clients, but some mixed responses from clinicians. A more negative response from one therapist was related to a perception of the approach being at odds with the skills and role of that professional.

Massimi, Berry, Browne, and Baecker present a descriptive treatment case study in which they describe the development and preliminary evaluation of “biography theatre”, an innovative technology designed to preserve selfhood in Alzheimer's disease. The participant's use of an “in-home ambient computer display” to continuously play autobiographical information was associated with decreased apathy and more positive self-image. This exploratory study is part of an exciting frontier of technological advances to support or maintain sense of self in the context of progressive neurological conditions.

Holistic rehabilitation was developed with the aim of integrating issues such as cognitive rehabilitation and return to productive activity with attention to identity and awareness changes (Ben-Yishay et al., 1985). Coetzer provides a review of the background to how identity issues are addressed in intensive holistic rehabilitation, and then describes an alternative service configuration for such work based on longevity of input, rather than intensity. The argument here is that identity change is slow and many people have very long term, albeit varying, needs following brain injury. Furthermore, the need to tailor the service to the particular rural community was also a consideration. A case is presented illustrating the work undertaken by this service.

In our view, the papers presented in this special issue spell out the complex and interacting processes across biological, psychological and social domains that are required for a clinically relevant appreciation of the nature of changes to self and identity in the context of neuropsychological rehabilitation. At the biological level, emerging literature suggests a systematic deconstruction of broad notions such as “self” and “sense of self” into subsidiary processes based on neuroanatomical organisation. Certain types of injury or illness may differentially target neurological substrates of self-related processes, thus constraining access to the representations required to support a full and coherent experienced and enacted sense of self. Technological interventions, as well as innovative rehabilitation techniques, may seek to address such underpinning deficits so as to return access to self-representation or sense of self to those with such impairments. It appears that there is some variation in the way people make sense of changes in themselves after injury, such as retaining coherence in sense of self although described as having poor self-awareness, or experiencing a sense of discrepancy with prior self or “hoped for” self. However, the placing of experience and development of sense of self and identity in social context also emerges as an overwhelming theme across many of the papers presented. Discourses and experiences in the contexts of families, services, tasks and roles may disempower some individuals, provide experiential evidence for negative self-perceptions, and thus maintain poor clinical outcomes. On the other hand, engagement in a range of social groups, the use of bi-directional feedback between therapist and client on performance on specific tasks in rehabilitation, and the use of metaphor and other techniques to link goal setting and rehabilitative activity to more adaptive “possible selves” and identities appear to yield some positive gains for restructuring self-representations and experienced sense of self. The clinical outcomes described in the issue are tantalising in their tentativeness but together spell out a number of testable hypotheses regarding change processes in rehabilitation. The ideas represented across the issue are not inconsistent with the early ideas that contributed to the development of the holistic model as presented by Ben-Yishay, but provide interesting extensions of notions well established in holistic rehabilitation. In conclusion, a range of biological, psychological and social models is now contributing to significant developments in understanding self and identity in rehabilitation and these promise growth in research and clinical interventions.