Transcript Document

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Grandma Masse’s Rules
for Success:
“The smart guys are the guys who learn
from the other guys. Don’t get all caught
up in one thing; everyone believes their thing is
the best thing and they’re usually wrong.
So, shut-up and listen and learn and change.”
In order to be successful
you’ve got to be eclectic.
More Grandma Masse
“Models collect dust on
shelves.”
Don’t fall in love with a particular
approach –
ideally, you’ll/we’ll
create a framework for intervention (a
working theory) that will evolve with
experience and evidence
So, why is self-regulation
so important?
Socially Unacceptable Behavior
Aggression
Impulsive Behavior
The Ultimate Result of Impaired SelfRegulation
Context Relevancy:
How does this stuff apply to
the bigger world?
adapted from Sailor, 1999
• Useful: Do the outcomes that we’re targeting produce
something useful to the individual in long run?
• Desirable: Does the individual choose the outcomes for
him/herself when given the choice? Is the individual given
thechoice of outcome?
• Social: Do the outcomes result in behaviors that will
increase interactions with persons other than paid staff?
• Practical: Will the behavior be used in real contexts
without staff support?
•Adaptable: Is there a focus on developing skills that
can/will be used in a number of situations and
without staff?
Most of the stuff that works is
conceptually simple but procedurally
difficult.
In many ways good intervention is
really about the systematic application
of common-sense.
Unfortunately, “common-sense is
terribly uncommon.” – Mark Twain
Three Beliefs That Will Affect the Likelihood
That You’ll Be Successful
 Optimism & Hope. Evident in the problems that are
targeted and the language that is used when
describing the individual and when interacting with the
individual.
 Appreciating the Influences of Contextual Factors
on Behavior. Requiring an understanding of the
setting events (the distant events on an individual’s
behavior).
 Applied Pragmatism. Recognizing that there is no
single “right” solution; moving away from the notion of
“consistent” use of a prescribed intervention strategy
to “concordance” on the part of all involved.
Introduction to
Intervention Ideas:
Conceptually Simple,
Procedurally Difficult
Why Do I Keep Making the Same
Mistakes?
Why doesn’t it Get Better?
Communication
Cognition
Behavior
COGNITION
Organization
Memory
Info Processing
Planning
Self Monitoring
Reviewing
Self-evaluating
Procedural vs. Declarative
Implicit vs. Explicit
Non-strategic
BEHAVIOR
COMMUNICATION
Excesses
Efficiency
Impulsiveness
Aggressiveness
Substance Abuse
Fluency/Articulation
Discourse
Effectiveness
Deficits
Initiation Impairments
Insight Impairments
Functional
Apparent
Behavior Interventions that Focus on the
Application of Consequences are
Dependent Upon:
HIGH REASON
(Intellect – “cool”)
 “Choosing the best option”
 Logical application of learned
outcomes
For the Most Part,
We Live in the Somatic World:
VISCERAL RESPONSES
(Gut feelings – “hot”)
 “I don’t know why! I just did.”
 Implicit application of experiences
Success via Learning from
Consequences
Presupposes:
Reasonable intactness of the neural networks
responsible for connecting:
Memory for the factual aspects of past behavior
and/or
Memory for the “Somatic Markers”, or the feeling states
associated with the consequences of those behaviors
Without these connections in memory,
past rewards and punishments
lack the power to drive future
behavior
An impulse
is not
a choice
When choice is offered, of course, it is
essential that the person being offered
the choice have the information
necessary for making a meaningful
decision . . . without such information,
being given a choice will feel more like
a burden than a support for autonomy.
- Edward Deci, 1995
Why We Do What We Do
Each waking day is a stage dominated for the
good or ill, in comedy, farce, or tragedy, by a
dramatis persona, the “self”. And so it will be
until the curtain drops . . . Although multiple
aspects characterize the conscious self, this
self is a unity.”
- Charles Sherrington, 1946
The Integrative Action of the Nervous System
Alliances are Critical to Success
1. When working with others in a concordant manner the
intensity, consistency, and duration of services
improves.
2. There is an increase in the probability of generalization
and maintenance of positive change (Brown’s Rule of
Three: Three people, three places, three times.)
3. There is a necessary infusion of reality, commonsense, and a functional focus of interventions.
4. “All of us are smarter than any one of us.”
Creating Alliances:
Three Rules of Thumb for Professionals
1. Demonstrate respect all the time, especially when
interacting with someone that you don’t like (or
who doesn’t like you!).
2. Seek the insights of everyday people - find the
hidden experts and use their expertise.
3. Keep your hat in your hand; never forget you will
always be a visitor in the life of the person with
whom you are working.
THAT’S WHAT I AM!
THAT’S WHO I AM!
RIGHT OR WRONG,
I CAN’T CHANGE THAT
CARLITO (AL PACINO), CARLITO’S WAY
“I’ve lived a very dysfunctional life,
and I know that that life has
shaped and molded me into
the person I am today.
I want to reshape myself.”
- Lloyd K.
Choice
(Noun)
1 The act of choosing; selection 2 the right,
power, or chance to choose; option 3 a
person or thing chosen 4 the best or most
preferable part 5 a variety from which to
choose 6 a supply that is well chosen 7 an
alternative 8 purposive discernment.
Impulse
(Noun)
1 a) an impelling or driving forward with
sudden force b) an impelling force;
sudden, driving force; push; thrust;
impetus 2 a) incitement to action arising
from a state of mind or external stimulus
b) a sudden inclination to act, usually
without premeditation 3 sudden
involuntary inclination prompting action.
Functional Conceptions of Choice:
• Free choice
• Fixed choice
• Forced choice
• Feeling the natural and logical results of
actions in the environment
For behavior-outcome linkages to serve
as motivators, people must understand
them, see them as relevant to their
lives, and have the capabilities for
utilizing them.
- Edward Deci, 1995
Why We Do What We Do
In other words: People need to have both the strategies
and capacities for attaining desired outcomes!
The
Three Big
Things
“When we think of your future – the next 10 years –
we need to think about the 3 most important
things to work on; the things that, if you achieve,
you’ll have a meaningful life.”
The 3 Things tend to cluster around these areas:
• Behavioral regulation/self-regulation
• Friendships/social-interaction
• Vocational skills/meaningful engagement
• Self-help skills
Being intrinsically motivated has to do
with being wholly involved in the
activity itself and not with reaching a
goal.
-Edward Deci, 1995
Why We Do What We Do
Making the “Big Things” Real
 Creating personal maps or steps to
attaining the personally meaningful
goals.
 Articulated by the individual (with some
help from staff, friends, family)
 Organized in a visual manner to assure
clarity
Step 55. I’m good at:
Me the: I need to:
_______
Step 3.
Step 2.
Step 1. I’m good at:
Me Now I need to:
KEEPING A HOTTIE BOYFRIEND
EULA’S STEPS
TO SUCCESS
BEING A GOOD PERSON
WITHOUT THINKING ABOUT IT
HANDLING MYSELF OUT OF CLASSES
DEALING WITH PROBLEMS
/BEING IN CONTROL
HANDLING MYSELF IN CLASSES
LISTENING TO GOOD ADVICE/IGNORING BAD
IN THE RESOURCE ROOM
HAVING A JOB, LIVING IN MY APARTMENT
PETER’S STEPS
TO SUCCESS
DON’T FORCE IT
GET OUT OF IT BEFORE
I GET INTO IT
MAKING PLANS BEFORE
GOING OUT IN THE WORLD
MAKING MEETINGS &
PARTICIPATING
IN THEM
FOLLOW MY PLAN
WHEN I’M OUT IN THE
WORLD
People, Places, Things
DEALING WITH
ASSHOLES POSITIVELY
MAKING MY PLAN TO STAY CLEAN EVERYDAY
& LETTING PEOPLE KNOW
IN A TREATMENT PROGRAM
Tom’s Plan & Tom’s Reality
A doctor
An EMT
Be a helping person
In rehab
More Intervention
Ideas:
Conceptually Simple,
Procedurally Difficult
PERSON
Mental Cognition
Health
Language Emotion
Volition
Behavior
Human beings are a collection of
relatively independent structures,
processes, and systems
John’s Cognition
Attention Perception
Arousal
Select
Direct/
Filter
Maintain
Divide
Shift
Memory
Organization
Encode/Store/Retrieve
Episodic/Semantic
Explicit/Implicit
Declarative/Procedural
Involuntary/Strategic
Working Memory/
Knowledge Base
Remote/Recent
Pro/retrospective
Iconic
Sequence
Categorize
Associate
Analyze
Synthesize
Reasoning
EF
Inductive
Deductive
Analogical
Divergent
Convergent
Goals for John - John will:
1. Increase duration of maintained attention
2. Increase prospective memory from 3 to 5 minutes
3. Increase category naming from 3 to 5 members per category
John’s Mental Health
Axis I
Axis II
Axis III
Axis IV
Clinical
Disorders
Personality
Disorders
General
Medical
Conditions
Other
Conditions
Mental
Retardation
Psychosocial
And
Environmental
Problems
Axis V
Global
Assessment
of Functioning
Goals for John: John will
1.
2.
3.
4.
Participate in psychotherapy sessions without falling asleep
Comply with his medication regimen as directed
Follow the recommendations of the clinical staff to assure his safety
Seek community services for his disorder and for his living
arrangements
John’s Behavior
John is the totality of his behaviors and
the systematic relationships among them
John
b1 b3 b12 b4 b1 b7 b62 b17 b17 b17 b4 b6 b9 b17 b12 b3 b8 b8 b5 b6 b17
Goals for John: John will
1. Increase frequency of b3 and b12
2. Decrease frequency of b17
Alternative Understanding of Human Beings
Sarah
Pursuing personally meaningful goals
While participating in culturally
valued activities
In social, cultural, and historical
contexts
Mediated as necessary by individuals
with greater expertise in that domain
Using cultural tools, such as
language, category schemes,
mathematics, organizational supports,
domain-specific strategies
In the presence of varied
context facilitators and barriers
Goal
Plan
Predict
Review
Do
Constructing an identity
that is meaningful and
sustainable is a primary
goal of intervention
“The self is not something
ready made but something in
continuous formation
through choice of action.”
- John Dewey
SENSE OF SELF FOR INDIVIDUALS WITH COEXISTING DISABILITIES
 Perplexity
 Unawareness or denial: Retention of




preinjury self-concept
Fragmentation
“I am a victim” (passivity; depression)
“I refuse to be a victim” (anger; aggression)
“I’ve changed; I’ve got my work cut out for
me” (resolve)
“IDENTITY MAPPING”







Identification of goals
Identification of image, hero, metaphor
Organization of identity description
[Creation of “identity map”]
Supported practice
Modification of others’ support behavior
Possibly meaningful project
Reconstructing/Constructing Identity
An Identity Map
FEELINGS
How does this
person feel?
FACTS
APPEARANCE
What has this
person done?
What does this
person look like?
POSITIVE
IDENTITY
METAPHOR
GOALS
PROCEDURES
What am I trying to
accomplish?
What will I
need to do?
IDENTITY CONSTRUCTION
Helping individuals with disability construct a
sense of personal identity that is:
 Satisfying/compelling
 Organized
 Adequately realistic
AND that includes the hard strategic effort
needed to be successful with a disability
“IDENTITY MAPPING”
 Identification of goals
 Identification of image, hero, metaphor
 Organization of identity description
 [Creation of “identity map”]
 Supported practice
 Modification of others’ support
behavior
 Possibly meaningful project
Identity Mapping: Cautions
 Professional competence
 Emotional fragility
 Professional imposition
 Cognitive prerequisites
 Meaningful language
Identity Mapping: Cautions
 Dangerous metaphors
 Negative use (e.g., “nagging”)
 Getting stuck; flexibility
 Heroes and victims
 Time post injury
Goals:
Facts:
TBI: 1991
Many injuries
11 weeks: hospitalization
Casts, scars, crutches
Multiple surgeries
Simply comply
Others set goals
No goals for self
Anger at driver and all authorities
Inadequacy, dependence
Hopelessness, frustration
Jason the
Victim
Appearance:
Crutches, casts, etc
People
Therapists, physicians, aides
Places
Hospitals, clinics
Feelings:
Action strategies:
No need for strategies; others take
responsibility
No sense of responsibility
Other people’s charge
Goals:
Freedom
Independence
Retribution (driver, any
Facts:
source of control)
Anger/Oppression
Victory!!!!
Former marine
Power/Control
(Exaggerated) sense of
Competence/Independence
Improvement
Zeal for justice
Disjointed life in
disarray
Feelings:
Jason the
Marine
Appearance:
Attempt to project power
People
Everyday people
Places
Everyday places
Action strategies:
When provoked, scorched earth policy
Demonstrate ability and power
Demonstrate others wrong
Experiment with new things
Try therapy (unsuccessful)
Goals:
First rate production
Make a clear statement
Facts:
Define self
Actor willing to be directed
Director
Mayor
Producer
Successful
Clint
Feelings:
Satisfaction
Accomplishment
Growth
Control
Focus
Eastwood
Appearance:
Action strategies:
Appropriate to the context
Contemplate versus react
Plan for success (daily strategy
formulation sessions;
daily plan sheets; barometer)
Script in advance
Practice taking alternative perspectives
Goal-Plan-Do-Review
Use supports wisely
People
Support people
Non-conflict people
Places
Reasons Why People Don’t Choose to Plan
When They Could
Adapted from Ellis & Siegler, 1997
• Planning requires delay in attaining goals and
the impulse for immediate gain is stronger than
the choice to delay an action
• Planning requires the suppression of currently
activated behaviors
• Individuals are often overly optimistic about their
success in the absence of planning, reducing the
perceived need for planning
• Planning takes time, and speed is often valued
over accuracy
A Community
Shared purpose
Recognition of individual needs
Ongoing articulation
of purpose
Identity(ies)/Roles/
Places/Jobs
Procedures for managing
situations when participants
are out of roles
Shared Projects
Procedures for feedback from
community members
Community Meetings
Staff Roles – Leader, supporter
Participant Roles – Leader, supporter, facilitator
The Importance of Community in
Establishing an Identity
 Communities help us to accomplish things.
 Communities are change agents.
 Communities are sources of meaning and belonging.
 Need to Belong (Baumeister & Leary, 1995)
 “The need to belong is a powerful, fundamental, and extremely
pervasive motivation.”
 A lack of belongingness constitutes severe deprivation and
causes a variety of ill effects.
“Alone.... Uh, I’m alone! I'm a lonely, insignificant speck on a has-been planet orbited by a
cold, indifferent sun. “ -Homer Simpson
 The Belongingness Hypothesis: A drive to form and maintain
at least a minimum number of lasting, positive, and
significant interpersonal relationships.
Social Identity Theory
 People have an innate and strong tendency to mentally
organize things and people into categories
 To the extent that we associate ourselves with
communities (i.e. categorize ourselves), we have social
identities
 Social identities (via our community memberships) are
important aspects of how we define ourselves
 To the extent that we identify with communities that are
valued (e.g., powerful, prestigious, high status, popular),
we’ll feel good about ourselves.
Projects
 Personally meaningful goal = product
SENSE OF SELF AND MOTIVATIONAL THEMES
 Expert role; helper/producer role
 Intrinsic motivation; meaningful engagement
 Anti-egocentrism
 Relevance, anti-oppositionality
 Awareness of strengths and needs
SOCIAL/BEHAVIORAL THEMES
 Meaningful context for practice of social/ interactive competencies
 Meaningful context for practice of collaborative, cooperative effort and
behavioral self-regulation
COGNITIVE THEMES
 Deep processing
 Planning and organizing
 Meaningful context for practice of all cognitive and “Executive
Function” processes
 G-O-P-D-R
 Compensatory strategies
 Integration of activity over time – day to day
 Integration of several contexts
SELF REGULATION DEVELOPMENT
Themes





Start early
Develop slowly
Continue into adulthood
Influenced by biologic and environmental factors
Variability: Context (person, setting and task),
motivation, culture
SELF-REGULATORY DEVELOPMENT:
The Role of Experience
Individuals are more likely to develop effective selfregulation if they:
 Experience adequate social attachment
 Experience an organized and predictable world
 Receive “authoritative/apprenticeship” parenting,
including effective modeling and verbal mediation
 Are rewarded for appropriate self-regulation and control
by others who value self-regulation and autonomy
Teaching a Learning
How to Think
 Think out loud.
 Think out loud a lot.
 Think out loud with the person: reflect, plan, problem solve, observe,
organize, evaluate, remember, review, create, etc.
 Make use of external supports when thinking: diagrams, photos, written
routines, day planners, notes, etc.
 Present yourself as an image of thoughtfulness. Help the individual to
embrace the notion that being thoughtful is a good and great thing.
 Think out loud in a way that shows that you are fun and flexible and
experimental in your own thoughts.
 Think out loud in a way that captures metaphors, analogies, similarities,
history, etc.
WHAT WE’VE LEARNED
OVER THE PAST 15 YEARS:
PRINCIPLES GUIDING THE DEVELOPMENT OF
SUCCESSFUL SELF-REGULATION FOR INDIVIDUALS
WITH CO-OCCURRING DISABILITIES
PRINCIPLE: ONGOING CONTEXTSENSITIVE ASSESSMENT
 Functional behavior assessment
 Collaborative hypothesis testing
 Engagement of the person in the
assessment process
 Assessment informs intervention/support
informs assessment informs
intervention/support
Contextualized Collaborative
Hypothesis-Testing
What’s the problem?
(Using the two strangers in the doorway rule)
Hypothesis Formulation
(Why is s/he doing this?)
Hypothesis Selection
(Begin with easiest to test
or most obvious)
Hypothesis Testing
(Protocol for experimentation
Plan A - Plan B - Plan C
Testing time line)
WHY TEST HYPOTHESES?
 Failure on any complex task is multiply
interpretable
 Complex students can be supported in
a variety of ways
 Test results do not necessarily indicate
how best to achieve success on
specific tasks
WHY COLLABORATE?
 Increase observations and experiments
 Increase compliance
 Educate family, staff, others
 EF training for student
 Show respect
WHY IN REAL CONTEXTS?





Inconsistency
Validity problems of standardized testing
Impact of setting, person, activity
Impact of stress
Observe real-world initiation, inhibition, selfmonitoring, problem solving
 Observe effects of real-world supports and
routines
 Observe support behaviors of others
PRINCIPLE: POSITIVE BEHAVIOR
SUPPORTS
 Environmental Focus
 Antecedent Focus
 Logical and meaningful consequences
 Skill Development
Alternative Behavioral Paradigms
A
B
C
Tradition: Behavior is
a function of its consequences
A
B
C
Positive Behavior Support
Alternative: Satisfying
behavior chains are
created with everyday
antecedent supports
Success via Learning from
Consequences
Presupposes:
Reasonable intactness of the neural networks
responsible for connecting:
Memory for the factual aspects of past behavior
and/or
Memory for the “Somatic Markers”, or the feeling states
associated with the consequences of those behaviors
Without these connections in memory,
past rewards and punishments
lack the power to drive future
behavior
Fluctuations in behavior are expected,
the goal of behavioral support is to make those fluctuations
manageable
High Risk/Unsafe/Unmanageable
Manageable
Risk
Behavior
Low
Risk
Manageable
Risk
High Risk/Unsafe/Unmanageable
Time
Fluctuations in behavior are expected,
the goal of behavioral support is to make those fluctuations
manageable
High Risk/Unsafe/Unmanageable
Manageable
Risk
Behavior
Low
Risk
Manageable
Risk
High Risk/Unsafe/Unmanageable
Time
PRINCIPLE:
THE PERSON IS THE CORE OF ALL
INTERVENTION AND SUPPORT EFFORTS
 Participation in goal setting and planning
 Case coordination
 Daily goal setting, planning, reviewing
 Participation in the assessment process
 Participation in selecting and managing staff
 Which person?? Helping the person to create an
identity that is:




Stable
Positive
Nondisability oriented
But inclusive of hard strategic effort
Goal-Directed
“Mature”
Identity Person-Centered:
Organize supports
around goaldirected choices
Synthesis:
Facilitate goaldirected choice
Medical/Expert
“Shallow”
Model:
Person-Centered:
I set your goals
“Whatever you
I make your
Say!!”
decisions
Anti-thesis:
Thesis:
Apparently irresolvable Enable
External
conflict
Impulsiveness
Control
Which Person??
“Person-Centered” Supports
 “Person-centered” does NOT mean never
having to say, “That’s not a good plan!! --That’s not a choice – that’s just impulse!!”
 Administrative challenges:
 Who is authorized to help the person
distinguish between choice and impulse?
 Who facilitates goal-directed choosing and
planning?
 What are the scripts for other staff?
 Clinical challenge: Mature identity
construction
PRINCIPLE: INTERVENTIONS AND
SUPPORTS ARE ORGANIZED
AROUND PERSONALLY
MEANINGFUL ACTIVITIES
“In the absence of meaningful engagement
in chosen life activities, all interventions
will ultimately fail”
 Option: School, work, volunteer
experiences, family responsibilities
 Option: Preparatory skill development
related to school, work, volunteer
experiences
 Option: Meaningful projects!!
PRINCIPLE: POSITIVE EVERYDAY
ROUTINES ARE THE CONTEXT FOR
PURSUIT OF MEANINGFUL GOALS
 Collaborative design of successful
everyday routines
 Recognition of adherence to routines and
plans
 Ongoing reinforcement of planning, routine
development, and maintenance of positive
routines: CELEBRATION of everyday
success!
“Routine is despair’s sly assassin”
PRINCIPLE: FEEDBACK IS CONTEXTSENSITIVE AND MEANINGFUL
GOAL – OBSTACLE – PLAN – DO – REVIEW
 Celebration of effective maintenance of
positive everyday routines
 Celebration of special contributions
 Identification of what works and what doesn’t
work
 Frank constructive feedback in response to
negative behavior delivered by a respected
staff person
Goal
Obstacle/Predict
Plan
Review
Do
PRINCIPLE: COMPONENTS OF LIFE
MUST BE INTEGRATED
 People have an innate and strong tendency to mentally
organize things and people into categories
 To the extent that we associate ourselves with communities
(i.e. categorize ourselves), we have social identities
 Social identities (via our community memberships) are
important aspects of how we define ourselves
 To the extent that we identify with communities that are valued
(e.g., powerful, prestigious, high status, popular), we’ll feel
good about ourselves.
A Community
Shared purpose
Recognition of individual needs
Ongoing articulation
of purpose
Identity(ies)/Roles/
Places/Jobs
Procedures for managing
situations when participants
are out of roles
Shared Projects
Procedures for feedback from
community members
Community Meetings
Staff Roles – Leader, supporter
Participant Roles – Leader, supporter, facilitator
PRINCIPLE: BECAUSE THE DISABILITIES THAT FOLLOW
BRAIN INJURY ARE TYPICALLY CONTEXT-BOUND,
CONTEXTUAL SUPPORTS ARE CRITICAL TO SUCCESS
Most critical to success:
 Effectively trained “everyday people”
 Collaboration between:
 Clinicians and support staff
 Natural and paid supports
 Participant and all supports: natural and paid
 Elaborative supports:
 Designed to expand domain of activity beyond disability
supports
 Designed to improving thinking and decision making
 Feedback: authentic and context-sensitive
Components of Self-Coaching &
Self-Advocacy Videos
 The negotiation and agreements that led to
the play (or script or identity map)
 For those with faulty recollection of the
rationale for the play (or script or IM)
 Educational content about the person’s
injury and its effects
 For the individual and Everyday Partners
 Educational content about the social,
vocational, or educational realities
surrounding the play (or script or IM)
Review of self-coaching in everyday
life
 At least weekly
 Scripts “feel” ok??
 Meeting goals? Reducing problems?
 Celebrate everyday successes!!!
 Never “failure” – if not working, try
something else
Goal of Self-Coaching
General goal: to improve planful goaloriented and ultimately successful
behavior while decreasing impulsive and
reactive behavior
Associated goal: to facilitate construction of
a positive sense of self based on effective
self-regulation/self-coaching and
ultimately successful social and
vocational participation
Why Self-Observation on Video?
 Repetition/habituation
 Context-sensitive automatization
 Particularly for those with limited processing
resources and weak on-line decision making
 Self-monitoring/self-awareness
 Everyday communication partner selfobservation
 Education:
 TBI information
 Social information
 Other
 Concreteness and immediacy
Self-Observation Cautions?
 Serious emotional vulnerability may rule
out video self-observation
 Perception of self can be disturbing
 Perceived image may be distorted
 Negative emotional states may be
exacerbated
 Protocol: A relevant professional
(psychologist, psychiatrist, social worker,
other trained counselor) needs to
authorize video self-observation in cases
of emotional vulnerability.
Goals of Self-Coaching Video
Variable
 Participant or ECP: Education about selfregulation
 Participant or ECP: Education about TBI
 Participant or ECP: Understanding of
specific obstacles
 Participant: Rehearsal of self-regulatory or
social scripts
 ECP: Negotiation and rehearsal of
acceptable cues or other scripts
PROCEDURES
Origin of need for specific self-coaching
scripts and video
 Participant
 Other participants
 Staff
 Family
 Other
PROCEDURES (CONT’D)
Negotiation of self-talk script or social script
 With counselor individually
 In counseling-oriented group
 In self-coaching group
 Collaborative process, with experienced
group leader guiding the process
S-C Video: Possible Components
 Introduction to concept of self-coaching
 Introduction to the participant’s specific issue – ideally
with the participant and calling attention to the brain
injury-related issues
 Possibly: brief vignette showing difficulty without use of
S-C script
 Brief vignette showing success with S-C script
 With ECP or highly respected person
 Possibly: brief discussion of need for practice and what
will be evidence of success
 Possibly “cheerleading” from peers
Some S-C “Plays” for Everyone
 The “Big deal/little deal” play
 Recognize/judge importance; block anxiety
 The “Let’s think about that” play
 Block impulsiveness; encourage thoughtfulness
 The “New play” play (football: “audiblize”)
 Encourage flexibility
 The “Am I ready?” play
 Block impulsiveness; encourage readiness
 The “Am I sure?” play
 The “What about you?” play
 Block egocentrism
 The “Hang in there” play
 The “Goal-plan-do-review” play
 Encourage goal orientation and planfullness
“The self is not something
ready made but something in
continuous formation
through choice of action.”
- John Dewey
Constructing an identity
that is meaningful and
sustainable is a primary
goal of intervention
IDENTITY CONSTRUCTION
Helping individuals with disability construct a
sense of personal identity that is:
 Satisfying/compelling
 Organized
 Adequately realistic
AND that includes the hard strategic effort
needed to be successful with a disability
“IDENTITY MAPPING”







Identification of goals
Identification of image, hero, metaphor
Organization of identity description
[Creation of “identity map”]
Supported practice
Modification of others’ support behavior
Possibly meaningful project
Reconstructing/Constructing Identity
An Identity Map
FEELINGS
How does this
person feel?
FACTS
APPEARANCE
What has this
person done?
What does this
person look like?
POSITIVE
IDENTITY
METAPHOR
GOALS
PROCEDURES
What am I trying to
accomplish?
What will I
need to do?
To Assure Long Term Success
Individuals Need to:
 Know that an event or activity will be difficult
 Establish reasonable goals (in some cases these might
be immediate)
 Formulate a plan to achieve the goal (or understand the
plan)
 Initiate goal-directed behavior
 Refrain from actions that interfere with the successful
achievement of goals
 Attend to and evaluate how well they are doing
 Try another plan or strategy if things are not going well
Teaching Self-Regulation is
Teaching People to Think
 Think out loud.
 Think out loud a lot.
 Think out loud with the person: reflect, plan, problem solve, observe,
organize, evaluate, remember, review, create, etc.
 Make use of external supports when thinking: diagrams, photos, written
routines, day planners, notes, etc.
 Present yourself as an image of thoughtfulness. Help the individual to
embrace the notion that being thoughtful is a good and great thing.
 Think out loud in a way that shows that you are fun and flexible and
experimental in your own thoughts.
 Think out loud in a way that captures metaphors, analogies, similarities,
history, etc.
ROUTINES
• Repetition creating temporal structure to improve memory
about relevant past events
• Cognitive predictions about what happens next
• Natural occasions for promoting cognitive growth
• An impetus for improvisation when trying to avoid
a negative outcome
are a necessary
prerequisite for
Planning
Concrete
Routines
Interaction
Routines
• Picture Routines
• Written Routines
• Language Routines
• Activity Sequencing
Routines to Deal with Changes in Routines
• What I do when what I expected
to happen doesn’t happen
Key “Executive System”
Concepts That Help Individuals
Learn Self-Regulation
Hard - Easy
Big Deal - Little Deal
Ready - Not Ready
Scary - Not Scary
Like - Don’t Like
Choice - No Choice
Interaction Scripts for Routines
Making Decisions
About the Goal
• “What’re you going to do?”
• “What are we here for?”
• “How will we know we’re done?”
• “We’ll know we’re done when
it looks like this . . . “
Making Plans
• “OK, so what’s the plan?”
• “What’ll you need to get this done?”
• “How will you and I know you’ll
need help?”
• “What will help look like?”
• “Don’t tell me what you don’t
want, tell me what you do want.”
• “OK, so what do you want me to do?”
Making Decisions About Ease or
Difficulty Before Beginning
• “Do you think this will be hard or easy?”
• “If it’s hard, then what’ll you need?”
• “Have you ever done this before?
What happened?
• “I don’t think I could do this! How do
you know that you can?”
• “Whaddaya think? Big deal or little deal?”
Coaching Through Problems
• “You look upset, is there anything
I can do?”
• “OK, you’re not ready. No problem;
just let me know when you’re ready.
• “I’ll know you’re ready when you
look like this . . .”
• “I’ll wait.”
• “You know we’ve gotta figure this
out, let’s try . . . “
• “I know it’s hard, but we’ve got
to do this.”
Coaching in Context
• “So, how’s it going?”
• “Is that helping you? Not helping?”
• “Is there anything else you can do?”
• “Is there anything I can do to help you?”
• “So when are you going to start?”
Review What Occurred
• “So how’d it go?”
• “How’d you do?”
• “Tell me exactly what happened . . .
and then what?”
• “What do you think other people
thought?”
• “What were you thinking when you . . .”
• “Next time you do this, what’ll you do
differently? The same?”
• “What helped?
• “What didn’t help?”
PRINCIPLE: REDUCTION OF
SUPPORTS IS PART OF THE PLAN
 Supports must be adjusted to fit needs and
abilities
 Systematic reduction of supports is
planned from day 1
 It is a goal of the waiver program to
empower people to succeed with natural
supports
COGNITION
Organization
Memory
Info Processing
Planning
Self Monitoring
Reviewing
Self-evaluating
Procedural vs. Declarative
Implicit vs. Explicit
Non-strategic
BEHAVIOR
COMMUNICATION
Excesses
Efficiency
Impulsiveness
Aggressiveness
Substance Abuse
Fluency/Articulation
Discourse
Effectiveness
Deficits
Initiation Impairments
Insight Impairments
Functional
Apparent
Reasons Why People Don’t Choose to
Plan When They Could
• Generating plans is no guarantee of success and
lack of past success influences the current
choice to plan
• An Individual may believe that s/he has no control
over outcomes, even if s/he does plan
 Planning is often unpleasant because it is difficult
or tedious or creates conflict
• An individual may assume someone else will
make a plan for him/her
• It’s often exciting NOT to plan
Helping People Choose to Plan
• DO NOT plan on planning in situations that have
historical impulsive routines in place
• Help individuals to “connect the dots”; make the
outcomes associated with planning explicit and
the likely outcomes associated with not planning
equally explicit
• Show the positive effects of planning for the
individual in the short term and long term
Helping People Choose to Plan
• Help the individual to make small/brief plans
with immediate outcomes
 Create a culture of planning early and often
 Plan with the person, not for the person
SR CHECKLIST
GENERAL CONSIDERATIONS
1. Is intervention in the areas that fall under the heading
"executive functions" structured around the individual's
own meaningful goals?
2. Is intervention infused into everyday activities? Are all
everyday people oriented to how they can facilitate
improved executive functions? Are all everyday people
aware of the dangers of learned helplessness?
3. Are everyday people aware of the strategies that the
individual is being taught or is expected to use?
4. Is successful performance in the areas grouped under
this heading richly and naturally rewarded? Is the
individual held responsible for effective strategic
performance?
5. Is the individual given ample opportunity to identify and
solve his or her own problems (with guidance if
necessary)?
SR Checklist (cont’d)
6. For individual's who are young or very concrete, are
executive function tasks structured around concrete
physical activities (versus abstract or cognitive
activities)?
7. Do everyday people in the environment routinely
model expert use of executive functions?
8. Is the individual given sufficient practice so that
strategic behavior becomes automatic?
9. Are everyday people in the environment supportive
of strategic or compensatory ways to accomplish
tasks?
10. Does the individual respect a strategic or
compensatory approach to everyday problems? If
not, is appropriate help/counseling provided?
11. Are everyday people in the individual's environment
fully aware of possible limitations in the individual's
executive functions (esp., initiation and inhibition) so
that they do not misinterpret behavior?
Self-Awareness of Strengths and
Needs
 Is the individual maximally engaged in identifying




what is easy and hard to do, and what makes
activities easy or hard?
Is the individual given opportunities to compare
performance when an activity is completed in a
usual way versus when it is completed with special
strategic procedures?
Does the individual keep a journal in which strengths
and needs are recorded?
Is the individual given opportunity to identify
strengths and needs in others, and strategic
procedures that others may use (e.g., peer
teaching)?
Is the individual given appropriate informative
feedback (e.g., peer feedback, video feedback,
confrontational feedback if appropriate)?
Goal-Setting
 Is the individual routinely asked to
predict how well he will do on
activities?
 Are predictions recorded in journals
and compared with actual
performance?
 Does the individual maximally
participate in rehabilitation/special
education goal setting? Is adequate
support provided if this is difficult?
 Are intervention activities structured
around the individual's personal goals?
Planning
 Does the individual participate maximally in




planning his or her intervention activities?
Is a planning guide available, if needed?
Does the individual begin the day by
preparing a plan on a planning board or in a
journal? Does the individual begin each
activity by preparing a plan?
Do therapy activities include attempts to plan
meaningful complex events (e.g., parties,
outings, etc.)?
Does the individual participate maximally in
long-term future planning? rehabilitation
planning? IEP development
Self-Initiating
 Do everyday people give the individual opportunities




to initiate and wait an appropriate length of time? Are
signals available to remind the individual to initiate
activities?
Do the activities that the individual engages in make
appropriate demands on the individual's ability to
initiate (e.g., board games may require little
initiation; conversations may require much
initiation)?
Are all forms of institutional "learned helplessness"
avoided?
Are prosthetic initiators available if needed?
If initiation cues are necessary, are they provided as
much as possible by peers versus staff? Is nagging
avoided?
Self-Inhibiting
 Do everyday people give the individual
opportunities to inhibit that are realistic in
their demands?
 Do the activities that the individual engages
in make appropriate demands on the
individual's ability to inhibit (e.g.,
unstructured and unfamiliar activities in a
distracting environment require considerable
inhibition)?
 If inhibition cues are necessary, are they as
subtle as possible and provided as much as
possible by peers versus staff? Is nagging
avoided?
Self-Monitoring/Evaluating
 Do everyday people give the individual
opportunities to self-monitor and evaluate
performance? If cues are necessary, are they
subtle? Is nagging avoided?
 Is the individual maximally involved in
charting his own performance? keeping a
journal in which performance is recorded?
graphing performance?
 Is the individual routinely asked to fill in a
form regarding his own performance: What
Works? and What Doesn't Work?
Intervention Goals
Sarah will successfully complete ___ meaningful task, with
___ supports, possibly using ___ “tools/strategies”, in
___ context (setting, people, activities), in order to
achieve ___ goal.
Possibly focusing intervention attention on some specific
aspects of cognition, communication, social skills,
behavioral self-regulation, or educational/vocational
skills – aspects that are either particularly weak or
particularly important for Sarah.
Teaching Positive Attribution
UNHELPFUL ATTRIBUTION
 “I can’t do anything well”
 “Teachers don’t like me”
 “Other kids are lucky”
 “Sometimes I get it; sometimes I don’t;
I don’t know why”
Teaching Positive Attribution
HELPFUL ATTRIBUTION
 “When I work hard and use my
strategies, I do OK; When I don’t, I do
badly”
 “Reading is harder for me than for
other students, but I can get it if I give
myself enough time and use my
strategies.”
Teaching Positive Attribution:
Procedures
 “Product Monitoring”
 Framing
 Self-Monitoring
 Hero Identification
 Procedures associated with “learned
optimism”
EXPERIMENT ROUTINE
“THIS WAY OR THAT?”
 Identify issue or conflict
 Try both ways
 Identify most successful
 General reassurance
EF SCRIPTS:
DELIVERY




Conversational, non-threatening interaction
Well-selected language
Avoid boredom, irritation
Mainly positive: “easy” “non scary” “not a
problem” “not a big deal”
 Massed and distributed practice (hundreds!!)
 Embedded in meaningful activity
 Across all everyday partners
PROBLEM-SOLVING SCRIPT
 Identify issue or conflict
 State the reason
 Generate a solution/strategy
 General reassurance
HARD TO DO/EASY TO DO
SCRIPT
 Identify task as hard or easy
 State the reason
 Generate a strategy (if hard)
 General reassurance
BIG DEAL/LITTLE DEAL
SCRIPT
 Identify the issue as a big deal or a little
deal
 State the reason
 Generate a strategy (if a big deal)
 General reassurance
SCARY/NOT SCARY SCRIPT
 Identify situation as scary or not scary
 State the reason
 Generate a solution/strategy
 General reassurance
Problem Solving/Strategic
Thinking
 Is the individual maximally involved in solving everyday problems






as they arise? Are everyday people thoroughly oriented to the
importance of problem solving?
Is the individual maximally engaged in selecting strategies to
overcome obstacles and achieve important goals?
Is there an appropriate amount of external support for strategic
thinking?
Does the individual have a form that cues the appropriate kind of
strategic thinking?
Do everyday people in the environment expect and cue strategic
performance?
Do everyday people in the environment avoid learned
helplessness, that is, do they resist solving all of the individual's
problems?
Is there consistency among staff and family members in how
problem-solving tasks are presented and in the kinds of external
problem-solving support that are provided? Is there consistency in
reducing external support as the individual becomes increasingly
independent in problem solving?
ROUTINES
• Repetition creating temporal structure to improve memory
about relevant past events
• Cognitive predictions about what happens next
• Natural occasions for promoting cognitive growth
• An impetus for improvisation when trying to avoid
a negative outcome
are a necessary
prerequisite for
Planning
Routine is despair’s sly
assassin.
Concrete
Routines
Interaction
Routines
• Picture Routines
• Written Routines
• Language Routines
• Activity Sequencing
Routines to Deal with Changes in Routines
• What I do when what I expected
to happen doesn’t happen
“Much of our cognitive life may be the
product of highly automated routines.”
- Gerald Edelman
Steps to Organize Routines of Everyday Life
1. Identify successful and unsuccessful routines
of everyday life. What’s working, what’s not
working?
2. Identify changes that have the potential to
transform unsuccessful routines into
successful routines (including changes in the
environment and the behaviors of others.)
3. Identify how changes in routines include
activities that are motivating to the individual
and everyday people.
Steps to Organize Routines of Everyday Life
4. Implement needed supports to organize
routines so that the individual experiences
success and receives intensive practice in
context.
5. Systematically withdraw supports and
expand contexts as much as possible.
Goal
Plan
Predict
Review
Do
Key “Executive System”
Concepts That Help Individuals
Learn Self-Regulation
Hard - Easy
Big Deal - Little Deal
Ready - Not Ready
Scary - Not Scary
Like - Don’t Like
Choice - No Choice
Interaction Scripts for Routines
Making Decisions
About the Goal
• “What’re you going to do?”
• “What are we here for?”
• “How will we know we’re done?”
• “We’ll know we’re done when
it looks like this . . . “
Making Plans
• “OK, so what’s the plan?”
• “What’ll you need to get this done?”
• “How will you and I know you’ll
need help?”
• “What will help look like?”
• “Don’t tell me what you don’t
want, tell me what you do want.”
• “OK, so what do you want me to do?”
Making Decisions About Ease or
Difficulty Before Beginning
• “Do you think this will be hard or easy?”
• “If it’s hard, then what’ll you need?”
• “Have you ever done this before?
What happened?
• “I don’t think I could do this! How do
you know that you can?”
• “Whaddaya think? Big deal or little deal?”
Coaching Through Problems
• “You look upset, is there anything
I can do?”
• “OK, you’re not ready. No problem;
just let me know when you’re ready.
• “I’ll know you’re ready when you
look like this . . .”
• “I’ll wait.”
• “You know we’ve gotta figure this
out, let’s try . . . “
• “I know it’s hard, but we’ve got
to do this.”
Coaching in Context
• “So, how’s it going?”
• “Is that helping you? Not helping?”
• “Is there anything else you can do?”
• “Is there anything I can do to help you?”
• “So when are you going to start?”
Review What Occurred
• “So how’d it go?”
• “How’d you do?”
• “Tell me exactly what happened . . .
and then what?”
• “What do you think other people
thought?”
• “What were you thinking when you . . .”
• “Next time you do this, what’ll you do
differently? The same?”
• “What helped?
• “What didn’t help?”
An Important Goal of Intervention:
Learning to Recognize Internal States
 Using some commonly understood
method of communicating “my” mood/
feelings/health, etc.
- Red – Yellow – Green
- A thermometer
- Rating Scales
Recognizing and Communicating My Internal State
I’m feeling great
I’m feeling really lousy
Project Based Intervention
 Present a project in terms of helping
others identify important information for
transitions
 Provide a context to evaluate and plan for
the “big picture” with Sarah and her family
 Provide a context to collaborate, as
consultants, with the team (e.g., the aide,
classroom teacher, vocational teacher, and
parents).
Project Approach:
Rationale
 Organizational impairment
 Superior involuntary learning
 Weak elaborative encoding
 Need for situated learning
 Need for errorless learning
 Need for routine learning
Project Approach
Rationale (cont’d)
 Internalization of mediated interaction
 Egocentrism
 Unawareness
 Intrinsic motivation
 Oppositionality
 Sense of self
 Self-esteem
Project Approach
 Meaningful goal; product
 Deep processing
 Planning and organizing
 Meaningful context for practice
 Integration of activity over time
 Integration of several contexts
 Expert role
 Helper/producer role
AARON’S RATING SCALE
Prior to, and following, each activity Aaron and his staff will evaluate his general mood using this scale. In
addition, the scale can and should be used during activities as a way of helping Aaron recognize his
mood changes, and the causes for those changes.
Aaron’s Indicators:
Red in the face
Staring
Lips clenched
Following directions
Making eye contact
Quiet
Swearing
PERSEVERATION
Destructive
Past the Red Line
Peaceful
1
2
3
4
Cool Zone – Blue Zone
5
6
Yellow Zone
“Use your strategies”
- take a break and move away
- talk about what your feeling
- listen to music
7
8
9
10
Red Zone
“Stop and breathe”
“Clear the deck”
- Get somewhere else quiet
Staff Scripts:
Use the “Hard – Easy” Script
-“Aaron is this hard or easy?”
- “OK, if it’s hard, no problem
I’ll give you some help.”
Use the Ready – Not Ready Script
-“Aaron you’re not ready to do this.”
-“I’ll know you’re ready when you look
like ________.”
The Job:
Help people to learn to develop,
and tell
THE STORY
Not simply report the news.
Four Lessons to Live by:
• Hope is an essential part of any successful plan of support.
• Form follows function. Think about what you need and
then create a way for that to happen in a flexible manner.
• The more you try to force something or someone to change,
the more it (or he or she) changes you.
• When all else fails, a sense of joy and a sense of humor
can get you through a whole lot!