The goal of this article is to describe and offer a rationale for an approach to cognitive rehabilitation labelled “context sensitive”. This approach stands in contrast to the modern tradition of cognitive rehabilitation that features massed and decontextualized process-specific cognitive exercises. The paper begins with theoretical considerations, emphasises the history of research in transfer of cognitive skill, incorporates the World Health Organization framework, describes context-sensitive apprenticeship procedures, draws on evidence accumulated over several decades with related disability groups, and ends with answers to frequently asked questions.

Many controversies remain with respect to how best to work with individuals who are challenged by cognitive impairments. Yet in the last decade, there has been substantial new research and a proliferation of literature, which has served to clarify major principles underlying cognitive interventions, and specified training procedures and teaching techniques that have demonstrated some effectiveness. Increasingly, it is possible to identify what techniques are likely to work for a particular individual, based on a number of variables including their cognitive profile, level of insight, and capacity for self-regulation. Education, the development of compensatory behaviours, the use of specialised instructional techniques and the inclusion of activities to improve self awareness and self-efficacy are but a few of the important components of most efforts at rehabilitation for cognitive impairments. Cognitive rehabilitation must be creative, eclectic, functionally oriented, and based in a partnership between clients, families/caregivers, and professionals.

Many studies of cognitive rehabilitation use neuropsychological tests to plan and evaluate treatment. This paper suggests that this is not a good rehabilitation procedure. The main purposes of rehabilitation are to achieve the maximum physical, psychological, social and vocational wellbeing of each individual and to enable people to return to their own, most appropriate environment. We do not engage in rehabilitation in order to help people achieve better scores on tests. This might be acceptable if there were a direct relationship between test scores and real life problems but there is not such a relationship. Although tests are useful in providing a picture of strengths and weaknesses, they are extremely limited in identifying everyday disabilities and handicaps. People can lead improved lives by compensating for or by-passing some of their cognitive problems yet remain unchanged on test scores. Conversely, they can improve on test scores yet remain severely handicapped in everyday life. One approach that is gaining ground in rehabilitation is goal planning. This allows patients/clients, their relatives and rehabilitation staff to negotiate appropriate and meaningful goals, determine how these should be achieved and measure success, or failure in real life situations. Goal planning both reduces the artificial distinction between rehabilitation practice and outcome measures, and allows the integration of theory and practice. The processes and procedures involved in goal planning are described and followed by an evaluative discussion.

Contemporary psychological literature as well as the preceding papers (Mateer & Sohlberg, 2003; Wilson, 2003; Ylvisaker, 2003) emphasise the individual patient's personal ecological context as a crucial factor in the delivery of cognitive rehabilitation services. Testing and assessment procedures in neuropsychology have been enjoined to take increasing notice of the patient's historical, cultural and social background in providing services (American Psychological Association, 2003). Similarly, the design and delivery of treatment services must take into account how and where patients are living their lives post-injury. This has the benefit of moving cognitive rehabilitation from an emphasis on the more obvious or face-valid concerns about sterile “cognitive” models to individual ways of facilitating learning and information transfer improvement in the real world. In this way of approaching the problem, the patient's cultural and demographic context as well as their emotional adaptations are not confounding variables but critical design variables. The challenge now in delivering these paradigms of care is to show that they are appropriate and effective in some place in healthcare delivery systems, whether traditional or alternative. Questions of effectiveness of cognitive rehabilitation treatments and cost should be balanced in an equation relating to the probability of objective and demonstrable patient enhancement in living. Goals set and achieved must have consensual value that cannot be captured by traditional cost-benefit analysis in preventive or curative healthcare economic methodology. Cognitive rehabilitation as a family of interventions has little to no chance of being evaluated as efficacious using traditional treatment designs, using traditional neuropsychological measures as dependent variables, and involving research designs with crossover, sham or placebo conditions.

Disorders of psychosocial function manifested in a reduction in socially skilled behaviour, are prevalent following traumatic brain injury. It is clear to most clinicians that these can present the major obstacle to successful rehabilitation. Outcome studies also support this view. Despite this, there is relatively little systematic work addressing social skills remediation in Australia or elsewhere. There are even fewer studies that have evaluated the effectiveness of social skills treatment after traumatic brain injury. In this address I will consider social skills from a social skills framework that has been developed in the normal literature. This framework encompasses social behaviour and social perception (i.e., the ability to read cues accurately and social problem-solving). Social behaviour is the most common target for remediation in both the normal and brain-injured populations. There is a range of useful techniques that have proven to be efficacious in treating social skills in non-brain-injured populations and also to have some effectiveness in the treatment of traumatic brain injury. In addition, however, it is clear that both social perception (i.e., the ability to read social cues accurately and social problem-solving are also compromised after TBI). These areas are infrequently targeted for remediation, although again, there are some remediation principles that are relevant and potentially fruitful. Finally, it is important to understand the impact of psychological reactive factors such as depression and poor self-esteem in producing or maintaining poor social skills.