Contemporary Behavioral Approaches: Techniques and

ResultsDebra Braunling-McMorrow, Ph.D.

V.P. DevelopmentNeuroRestorative

debra.mcmorrow@thementornetwork.com

PURPOSE

• Understand Contemporary Rehab. And Behavioral Themes

• Understand the importance of antecedent based approaches in responding to and preventing behavioral issues

• Understand Behavioral Sequences and the Importance of Windows of Opportunities in Providing Support

• Use Personal Intervention and Other Approaches• Achieve Meaningful Outcomes

SOME BEHAVIORAL ISSUES AFTER ABI

• Diminished awareness of difficulties• Predictable topic/situations that produce upset• Tendency to rationalize or blame others for problems• Tendency to perseverate during upsets• Others “walk on eggshells”• Diminished Problem solving skills under stress• Difficulty receiving “corrective” feedback• Resistance to traditional rehabilitation agendas• Behaviors that produce risk to self or others• Post injury Experience with “Behavior Management”

Where are people with brain injuries who have

behavioral issues?…………

BRAIN INJURY AMONG THE HOMELESS

• MN Plan to End Long-Term Homelessness– Of 1,320 homeless individuals, 39% report possible BI.

(Heading Home project April, 2008)

• Assessment of 100 homeless men in NY found 82% suffered brain injury in childhood, primarily as a result of parental abuse (Gordon, et. Al., 2006)

• 23% of homeless population are veterans– 47% Vietnam era– 67% served 3 or more years– 89% received Honorable Discharge

(Interagency Council on the Homeless, 1999)

BRAIN INJURY AMONG PRISONERS

• Studies indicate TBI occurs among an estimated 25-87% of the jail and prison population (Walk. Helgeson, Langlois, Brain Injury Professional, 2008)

• In contrast, to an estimated 8.5% of non-incarcerated adults (Silver, et. Al., 2001)

SOME CONTEMPORARY THEMES IN BEHAVIORAL INTERVENTION

• Outcome Driven• Proactive/Non-Intrusive• Person Centered• Self-Managed• Interactional• We all wear the hat of a behavior analyst

SOME BASES OF BEHAVIORAL INTERVENTION

• Thoughts, Feelings and Actions are “things”• “Things” happen for a Reason… they are caused• Sometimes we can change “things”• We make decisions whether behavior is “good” or

“bad”• There are two main ways to change “things”

(Stop old or Start new)• Contemporary Themes influence Practice

APPROACHES TO BEHAVIOR CHANGE

ONE WAY ANOTHER WAYFocus Single Behavior Complex SequenceGoal Reduce Inappropriate Increase AppropriateStyle Reactive Proactive

Timing Consequence (After) Antecedent (Before)Intent Provider Control Personal ControlLocale Excluded Site Included Site

Purpose Manage Behavior Empower ParticipantFlavor Impersonal Mutually Reinforcing

CHANGING BEHAVIORHaving an impact on the things that happened

before or after behavior

1. Discouraging “old ways” of behaving after they occur (REACTIVE APPROACH)

2. Removing certain causes as behavior is happening (PASSIVE APPROACH)

3. Encouraging new ways of behaving when the causes show up (PROACTIVE APPROACH)

PREDISPOSITIONSWe are all “predisposed” to behave in particular

ways based on “what we bring with us” to a particular situation. Persons with ABI bring a complex combination of pre and post-injury

factors.

SOME PREDISPOSING FACTORS: Learning History, Medical Conditions, Medications, Neurological Status, History of Trauma, Substance Exposure, Treatment History, Sleep Deprivation, Interactional History, Emotional Backdrop, Environmental Stimulation, etc.

ANTECEDENTSEvents that occur in some temporal proximity to the

behavioral sequence of interest that are believed to play a causal role in their onset

SOME POTENTIAL ANTECEDENTS: Difficult Tasks, Particular Individuals, Environmental Conditions (e.g., heat, clutter, noise, etc.), Presence of Desired Objects, Particular Interactions (e.g., criticism, public corrections, competition, etc.)

WHEN THE “HEAT COMES ON THERE ARE FOUR GENERAL WAYS THAT PEOPLE CAN RESPOND…

1. ESCAPE OR AVOID2. WITHDRAY OR “FREEZE”3. GET EMOTIONAL4. PROBLEM-SOLVE

• ACTING ANY OF THESE WAYS MAY SERVE TO MAKE A DIFFICULT SITUATION LESS DIFFICULT

• THE PROBABILITY OF 1, 2, & 3 ARE IMPACTED BY AN INDIVIDUAL’S ABILITY TO PROBLEM-SOLVE

PERSONAL INTERVENTION AT A GLANCE

HIGH

LOWTIME

AROUSAL

From McMorrow, 1994

NOW IS TIME FOR ACTIVE TREATMENT AND

PERSONAL INTERVENTION

NOW IS TIME FOR RISK MANAGEMENT

An escalating sequence of behavior

TREATMENT APPROACHES• Philosophical Stands and Commitments• Residential Array or Continuum• Interactional Style / Proactive De-escalation• Integrated Staffing and Service Delivery• Personal Intervention Training• Goal Setting Activities• Functional Cognitive Rehabilitation• Performance Monitoring• Risk Management / Com. Access Review

STANDS AND COMMITMENTS OF A PROACTIVE APPROACH

• Emphasis on Positive/Mutual Reinforcement• Avoidance of methods based on punishment,

extinction, or escape-extinction learning operations

• Minimal medication regimen and no PRN’s• Least restrictive treatment (no fooling!)• No mechanical restraint or exclusive/seclusion• Keep participants involved in the life of their

community• Treat all participants with respect and dignity (no

matter what…)• Include “stands” as a part of quality assurance

measures

THEMES OF PROACTIVE REHABILITATION

• Create pathways to obtain preferences• Establish “type 2” reinforce-reinforce reciprocity• Establish problem-solving skills in difficult

situations• Increase probability of problem-solving by

maintaining low arousal• Graduate exposure to more difficult situations to

enhance experience of success

INTERACTIONAL “DO’S”(interacting with confused and agitated)

• GET YOURSELF ORIENTED• DEVELOP A CHARACTERISTIC INTERACTIONAL

STYLE• GRADUATE EXPOSURE TO ENVIRONMENT,

OPPORTUNITIES, REHAB EXPECTATIONS• ENCOURAGE SAFE EXPLORATION• DISCOVER PREFERENCES• LEARN TO “LISTEN”• BOUNCE BACK QUICKLY FROM PROBLEMS• REACH AGREEMENTS

RECIPROCITY GOES BOTH WAYS

RECIPROCITY IS AN ONGOING EXCHANGE OF SIMILAR INTERACTIONS.

(THERE ARE TWO TYPES OF RECIPROCITY)

1. ATTACK – ATTACK/NEGATIVE(“EYE FOR AN EYE”)

2. REINFORCE – REINFORCE/POSITIVE(YOU SCRATCH MY BACK AND I’LL SCRATCH YOURS)

Eye For An EyeWill Make the Whole

World Blind Gandhi

COMPONENTS OF ACTIVE TREATMENT INTERACTION

P Positive

E Early

A All

R Reinforce

L Look

_________

PEARL

McMorrow & Kirkpatrick, 94

SOME BEHAVIORAL DE-ESCALATION PROCEDURES

RESPONSE PRIMING

REFELCT AND REASSURE

STIMULUS CHANGE (X2)

INTERSPERSED REQUESTS

FOCUSED REDIRECTION

REINFORCER RECALL

TOPIC DISPERSAL

FUNCTIONAL REPLACEMENT

BEHAVIORAL MOMENTUM

COMPONENT OF A PERSONAL INTERVENTION PLAN

An individualized compensatory strategy for managing emotions and behavior

in difficult situations

• LIST PREDISPOSING FACTORS• LIST EVENTS OR ANTECEDENTS TO UPSETS• IDENTIFY SEQUENCE OF UNWANTED BEHAVIOR• LIST DESIRE REPLACEMENT BEHAVIOR• IDENTIFY SUPPORT NEEDED FROM OTHERS

WHAT IS PERSONAL INTERVENTION?

1. An individual plan for managing one’s emotions and behaviors in difficult situations.

2. A contemporary way of teaching behavioral self-management and providing support for persons who are learning.

3. A compensatory strategy for persons who have difficulty problem-solving in high arousal conditions.

A Simple Personal Interventions Plan for ________

This plan is intended to assist you and those who may help you to learn more about yourself and get better at managing your emotions and behavior when the going gets tough. Consider it as a representation of ways you have responded in the past and a new

start on waysyou may use it in your future.

1. I am likely to have a bad day when…(List at least three situations that may precede a “bad day.”)

2. I am likely to get upset when…(List at least five events that produce upset for you.)

3. When I get upset, I notice a sequence that starts with __________ and may end with ___________.(Make a list from the first sign to other things that do or could occur.)

4. When I notice that a difficult situation is coming or when I begin to get upset, I will have the most success when I…(List the steps you need to take.)

5. Other people can help me by…(Identify who you need to help and list what you need them to do.)

Center for Comprehensive Services, Inc.Abbreviated Summary of the Functional Area Outcome Menu1

Level ofFunctioning

ResidentialStatus

Level ofIndepend.

BehavioralAnd

EmotionalStatus

CommunityParticipa-

tion

Level ofAwareness

VocationalEndeavors

EducationalEndeavors

InvolvementIn

Vocation orEducation

Level ofSelf

ManagedHealth

IntimacyRelation-

ships

QualityOfLife

5Maximum

At homeandIndependent

CompletelyIndependent17-24 hrsper day

Selfmanageswith noassistance

Productiveactivitiesdaily

Anticipatoryawareness,canconsistentlyplan ahead

Competitiveemployment

Regularclassroom

Full-timeparticipation

SelfInitiatesmedicalroutines

Mutuallysatisfyingrelationshipintimacyand friends

High qualityof life

4 Home orapartmentwith support

Independ.9-16 hoursper day

Selfmanageswithoccasionalassistance

Productiveactivities,but notdaily

Emergentawareness,maysometimesplan ahead

Noncompetitiveorsupportedemployment

Classroomwithformalsupport

¾ timeparticipation

Requiresdirectionguidancefor complexmedicalissues

Reportsrelationshipwith friendsor intimate> 1 time/wk.

Person isoften happy

3Intermediate

Congregateliving.Staffavailable24 hrs/day

Independ.5-8 hoursper day

Selfmanageswith dailyassistance

Errands andleisureactivitiesweekly

Intellectualawareness,inconsistentlyinitiatesstrategies

Shelteredorspecializedemployment

Selfcontainedclassroom& regularclassroom

½ timeparticipation

Managesbasicmedicalonceprompted

Casualrelationship,activitiesout of homeat least1 time/wk.

Generallyhappyexhibitsproblemsdealing withday to day

2 Post-AcuteRehab.setting

Independ.up to 4 hrs.per day

Minimallyresponsiveto externalintervention

Errands,leisureactivitiesone timeper weekor more

Identifiesskill anddifficultiesonceprompted

Avocationalprogram

Selfcontainedclassroomonly

¼ timeparticipation

No selfmanagementskills ofmedicalroutines

Interactswith othersonly forbasic needs

Person israrelyhappyDifficultywith day today issues

1Minimum

Institutionalsetting

Requires24 hourassistance

Activelyresistsexternallymanagedinterventions

Nocommunityparticipation

Cannotidentifyany skill ordifficulties

Noparticipation

Noparticipation

Noparticipation

Resistant tomedicalinterventions

No contactor activelyresistscontact

Person isconsistentlyunhappy ormiserable

1 Braunling-McMorrow, D. & Tompkins, S. (1994). Measuring outcomes: A model for post-acute rehabilitation programs for persons with TBI. Center for Comprehensive ServicesMonograph, 1(4). Carbondale, Illinois: Center for Comprehensive Services, Inc.Revised Braunling-McMorrow, D. Neumann, T.(1999)

Functional Areas

NeuroBehavioral Programs

1

2

3

4

5

Reside

ntial

Indep

ende

nce

Behav

ior

Communit

y

Awaren

ess

Vocati

on

Educa

tion

Involv

emen

t

Quality

Health

Relatio

nship

s

Total persons admitted - 676Total persons one year follow-up - 227

Leve

l of I

ndep

ende

nce

REHAB GROUP X INTERACTION

0.5

0.75

1

1.25

1.5

1.75

<6 mo 6-12 mo >12 mo

TPI Group

Gai

n So

lo

NB

Thank YouDebra Braunling-McMorrow, Ph. D.

Vice President DevelopmentNeuroRestorative

(formerly MENTOR ABI)

Debra.mcmorrow@thementornetwork.com

Suggested Readings:Getting Ready to Help: A Primer on Interacting in Human

ServiceM. J. McMorrow, Brookes Publishing 2003www.brookespublishing.com

BRAIN INJURY PROFESSIONAL 2009 VOL 5(4) BEHAVIOR: RESPECTING INDIVIDUALITY AND PROMOTING ABILITY

NORTH AMERICAN BRAIN INJURY SOCIETY

BEHAVIORAL CHALLENGES AFTER BRAIN INJURY, 2007BIAA www.biausa.org

LASH AND ASSOCIATES PULISHING AND TRAININGwww.lapublishing.com