When “Presenting Well” Becomes a Risk

When “Presenting Well” Becomes a Risk: Rethinking Social Work Brain Injury Assessments

This article is under review for publication in British Association of Social Workers.

In my work with people who have acquired brain injuries, I have learned that some of the most vulnerable individuals are also the ones who appear the most capable. They sit in assessments, speak clearly, describe their difficulties, and seem to demonstrate insight. On the surface, they present exceptionally well.

Yet once the assessment ends and everyday life resumes, things can unravel quickly. This is not a failure of assessment skill, it is a reflection of how brain injury works, and how much of it remains hidden unless observed over time.

The hope of this article is to provide some key considerations when performing needs assessments. And to highlight that although collaboration with specialist brain injury providers extends the assessment process, it is indispensable. It is the only way to truly understand the person beyond the snapshot and see the reality of their lived experience.

The Limits of the Snapshot

Social work assessments are snapshots: one moment in one environment. For many people with brain injury, this moment shows them at their very best. Assessment rooms are structured, predictable, quiet, and supported — the exact opposite of the environments where difficulties tend to arise.

Brain injury frequently affects executive functioning: planning, sequencing, organisation, emotional regulation, and the ability to initiate or follow through. These challenges are rarely visible in a short interview. A person may clearly explain what they should do, yet be unable to carry it out independently or consistently.

What looks like functioning is often simply good self-report.
What sounds like insight may actually be learned language, not lived awareness.

None of this is intentional. It is a neurological consequence of injury, and one that can easily mislead.

A Case Example

I often think of a woman in her thirties with a significant brain injury. In assessments, she was articulate, composed, and knowledgeable about her condition. She listed her impairments precisely. She appeared to understand her risks.

But her “insight” was learned, not applied. In daily life, she could not recognise her impairments or connect them to her decisions.

The courts deemed her unable to take care of her child, but when assessed for support she presented so well that she received minimal support. Despite my concerns about her functioning, safety, and deteriorating mental health, the realities of her day-to-day life were not reflected in statutory decisions. Reports went unread. Evidence was dismissed.

The consequences were sadly predictable:
Safeguarding concerns, exploitation, police involvement, repeated mental health crises, and growing distrust. Not out of defiance, but from confusion and grief.

Fortunately, after years of advocacy, her support needs were fully acknowledged, and her support package increased. The financial impact for services was a small increase in the cost of care, but a massive decrease in the cost of additional services. With consistent specialist input, her life stabilised. No more admissions to secure units, no more police involvement, no more safeguarding concerns raised.

The outcome for her was profound and she was reunited with her child through contact visits.

This was not a failure of due process. It was a failure to recognise the hidden nature of her brain injury, and to value the observations of those who saw her daily.

The “Walking Wounded”

There is a group often described as the “walking wounded” — individuals who are not visibly disabled, but who struggle profoundly in everyday environments. They are often considered:
• “Too able” for specialist services
• “Too complex” for generic support

They may hold themselves together in an assessment yet fall apart at home. They can appear organised for an hour but cannot sustain routines, manage finances, or avoid unsafe situations when left on their own.

Everyday challenges require far more cognitive and emotional energy after a brain injury. Fatigue, memory issues, slowed processing, emotional dysregulation, and low stress thresholds all combine to make ordinary life extremely difficult. These difficulties are often misinterpreted as:
• non-engagement
• inconsistency
• laziness
• “unwise decisions”

These behaviours are symptoms, not choices.

Insight vs Awareness

One of the most complex features of brain injury is the gap between insight and awareness.

• Insight: being able to describe your impairments
• Awareness: recognising those impairments as they are happening

Many clients can list their difficulties in a calm setting, yet have no awareness of them in the moment. This disconnect shapes risk, behaviour, and decision-making, but it is almost impossible to detect in a single conversation.

The Role of Fatigue

Fatigue is one of the most disabling but least visible consequences of brain injury. Unlike typical tiredness, brain injury fatigue affects:
• emotional stability
• memory and attention
• processing speed
• problem-solving
• behaviour regulation

A person may appear capable during an assessment, yet be unable to function an hour later. This is one of the biggest reasons why short assessments give an incomplete picture.

Capacity, Vulnerability, and Hidden Risk

Many people with brain injury meet the formal criteria for capacity. They can:
• understand information
• retain it briefly
• communicate a decision

But they may still be profoundly vulnerable.

I have supported clients who could repeat information back during an assessment yet forget it minutes later. Unable to use it, weigh it, or apply it. Each decision was made in isolation, without continuity or learning. On paper, they were capacitous. In reality, they were at significant risk of exploitation or harm.

We must respect autonomy, but must also acknowledge cognitive vulnerability.

Why Collaboration Is Essential

Brain injury is complex, inconsistent, and largely invisible. No single assessment can capture the full picture.

Specialist brain injury services see what statutory assessments cannot:
• behaviour under stress
• functioning at different times of day
• the impact of fatigue
• real-world safety
• patterns that emerge over time
• the gap between intention and ability

Social workers carry heavy caseloads in an overstretched system. It is unrealistic to expect every practitioner to have specialist brain injury training.

This is why collaboration is not optional, it is essential.

When statutory services work closely with brain injury specialists:
• risk is understood more accurately
• support is more appropriately allocated
• crisis, breakdown, and long-term cost are reduced
• clients receive support that matches their actual needs

When we value lived observation as much as self-report, we do more than improve assessments.

We prevent harm.
We protect autonomy.
We change trajectories.

And for some people, that change is everything.