Interacting with People who Experience Behavioral Residuals of Brain Injury

Martin J. McMorrow, MS The MENTOR Network ABI Group Center for Comprehensive Services [email protected]

Definition - TBI

Traumatic brain injury is an insult to the brain, not of a degenerative or congenital nature but caused by external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of

cognitive abilities

or

physical functioning

. It can also result in disturbance of

behavioral or emotional functioning

. These impairments may be temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.

(Causes = ~50% MVA’s, Falls, Military Shock blasts, etc) (NHIF, 1996)

Definition - ABI

An acquired brain injury is an injury to the brain that has occurred after birth and is not hereditary, congenital or degenerative. The injury commonly results in a change in neuronal activity, which affects the physical integrity, the metabolic activity, or the functional ability of the cell. The term does not refer to brain injuries induced by birth trauma.

(Causes = Tumors, stroke, toxins, infections, anoxia, etc) (BIAA, 1997)

TBI Prevalence - USA

• 1,500,000 hospital ER contacts annually • 1,000,000 treated and released from ER • 230,000 hospitalized and survive • 80,000-90,000 left with long term disability annually • ~5,100 annually will require ongoing/intensive behavioral services and supports (6% of those disabled) • ~6,000,000 persons living in USA with permanent disability from TBI • ~360,000 in need of ongoing/intensive behavioral services and supports (from CDC, BIAA,&NASHIA)

Characterizing BI Services in USA

• ~400+ hospital, community, and home-based BI programs • About 1/2 of States now have dedicated HCBS BI Waivers • ~6000 individuals served on all BI Waivers at a cost of ~$80,000,000 annually (average of about $36 per day) • Others with BI are served on MR/DD, AD, and other Waivers or in mental health, corrections, or nursing settings • Very few persons with BI receive the rehabilitation or support services that are recommended for them • Many more than 1/2 of BI programs report providing “behavioral intervention” service specialty, yet

very

few include certified or trained Behavior Analysts

Characterizing BI Services (Observations)

To Reduce Costs of Care...

• Medical stabilization is quicker • Acute and sub-acute rehabilitation is shorter • Post Acute

rehabilitation

seems less likely • Decreased involvement by “Specialists” • Increased involvement of families and allied health staff • “Menu’s” of reimbursed services with limits • Administration of BI services by “generalists” What does this mean in terms of technology development and training?

One Cut at Behavioral Issues after BI

• Diminished “awareness” of difficulties • Predictable topics/situations that produce upset • Tendency to rationalize or blame others for problems • Tendency to perseverate during upsets • Others “walk on eggshells” around the person • Diminished problem solving skills under stress • Difficulty receiving corrective feedback • Resistance to typical rehabilitation agendas (PT, OT, SPL) • Behaviors that produce risk to self or others (= Psych) • Post injury experience with “Behavior Management”

3000 2500 2000 1500 1000 500 0

Issues displayed by persons in Neurobehavioral Rehab 1998-2006 Type of Issue

Human Service Interaction Guidelines

Adapted from the book

Getting Ready to Help: A Primer on Interacting in Human Service

(McMorrow, 2003 Paul Brookes Publishing)

Our Beliefs are Consistent with...

• Treating people with “dignity and respect” • Positive, proactive, antecedent-based approaches • Positive Behavioral Supports • Person Centered Planning • Applied Behavior Analysis • Personal Intervention Training • Active/Outcome Oriented Treatment • Social Capacity Building

We believe that...

Helping others is about

interacting

in a way that produces some sort of desired change for the person being helped

We also believe that there are certain concepts that underlie human service interaction and that (if we can learn, practice, and use them) we can become very good at our work and enjoy it even more.

#1. Do No Harm (A) To get in a position to help, the individual must have an interest in interacting with the helper

A. We can’t interact in a way that drives others away (Any specific interaction we have that reduces the future probability of interacting might be considered

punishment

) Examples: May include verbal correction, feedback, criticism, reprimands, referring to people with labels, ugly facial expressions, as well as delivery of “consequences” such as removal from an area or denial of access to privileges.

#1. Do No Harm (B)

B. We can’t consistently fail to respond when individuals seek out interaction with us ( Failing to respond may produce more vivid attempts to communicate an interest in interacting or, worse yet,

extinction

of approach responses) Examples: Consistently ignoring initiations, spending our time in more preferred activity, interacting with persons who are viewed as more fun.

#1. Do No Harm (C)

C. We can’t make up “silly rules” about what is required for an individual to have our interactional attention (We may want to teach desired ways to request interaction, but these ways must be within the person’s skill set) Examples: Expecting an individual to stand outside arm’s reach, say “please” and “thank you,” and interact no more than once every 30 minutes may be unreasonable.

Can we learn to respect an individual’s disability?

#2. No one is “to blame”

• We need to be clear what we expect from people • It is helpful to consider that every “thing” a person does has a cause(s), even though we may not know what it is (behavior is complex and purposeful) • It is also helpful to consider that some of these causes are “internal” (such as pain or illness) and many others are external (such as loud noises and interactions with others in the environment) • Getting in the practice of “looking for causes” can reduce our tendency to blame people for the things they do • It can also make helping very interesting

What happens when we “blame” people

• Blaming

people

for the things they do often leads to fault finding • Fault finding often leads toward treating people rudely (e.g., they “deserve” it because they are at fault) • Treating people rudely usually produces more rude interactions

What happens when we refrain from blame

• We begin to look “beyond the person” for the causes of his or her behavior and begin to see “things” in a broader “context.” • We begin to think a little like a scientist... looking for the relations between things just makes more sense • We begin to see that we can

sometimes

change behavior by changing causes - not people • We become much less inclined to fall into the “blame trap”... finding fault in those we serve and treating them rudely (which is really no fun and solves nothing) • Human service work can become a lot less frustrating and much more rewarding

#3. Look for Interactional Reciprocity

“There seems to be a natural inclination to be reinforcing to those who reinforce us, as there is to attack those who attack us.”

B.F. Skinner, 1971

Interactional Reciprocity Defined

An

ongoing

interaction between two individuals or groups of individuals (e.g., neighborhoods, governments, cultures, etc.) that is characterized either by the regular exchange of “positive” or “negative” events.

Two types of Interactional Reciprocity

1. Attack - Attack (“Eye for an eye”) Examples: The proverbial Hatfield’s and McCoys, Israel and Palestine, Democrats and Republicans?, other.

2. Reinforce - Reinforce (“You scratch my back and…) Examples: Many good marriages, friendships, etc. Are there any examples in the room? *Reciprocal interactions are everywhere. Watch for them.

“Eye for an eye will make the whole world blind”

mahatma gandhi

#4. Establish Mutually Reinforcing Relationships

Our overriding goal is to establish an ongoing, mutually reinforcing relationship that

both

parties in the interaction are interested in having

“How to” establish a mutually reinforcing relationship

• Learn to recognize when it exists (or not) in your life • Understand that it is a job expectation, not just a nice idea • Recognize that it is part of your job to be the start of this sort of ongoing interaction with those you serve • Use a high frequency of “positive” interactions, especially with persons you have just met • Recognize when your positive interaction is being “returned” and acknowledge it (e.g., “thank you”) Helping can then be viewed as an “exchange” of reinforcers • Make sure that difficult tasks/requests are introduced only against a rich backdrop of positive interactions

# 5. Teach in ways that empower (Personal Intervention Plans)

• “Give a person a fish and you will feed him for a day. Teach a person to fish and you will feed him for a lifetime…” • Viewing “emotional/behavioral” control as a skill that one really needs to learn • Viewing the creation of any “behavioral plan” as a

participatory

affair • Viewing emotional/behavioral self-management like any other compensatory behavior

What is Personal Intervention?

1. An individualized plan for managing one’s emotions

and

behaviors in difficult life 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.

THE PERSONAL INTERVENTION PLAN TEMPLATE

1. Identification of general “

predispositions

” 2. Identification of specific

antecedents

that create problems 3. Hierarchal ordering of

unwanted emotional sequence

4. Identification of

desired/effective alternatives

5. Identification of interpersonal

supports for use of alternatives

Approaches to Assisting Behavior Change

Focus Goal Style Timing Intent Locale Purpose Flavor ONE WAY Single Behavior Reduce Inappropriate Reactive Consequence (After) Provider Control Excluded Site Manage Behavior Impersonal ANOTHER WAY Complex Sequence Increase Appropriate Proactive Antecedent (Before) Personal Control Included Site Empower Participant Mutually Reinforcing

#6. Bounce off the Upsets

• Upsets are in response to something that has happened around the person (What has changed?) • Upsets typically reflect the person’s best effort to deal with whatever is happening (to obtain something desired or produce relief) • Upsets almost always happen in a sequence…the earlier we become involved in the sequence, the better • When risks are present, “Protect now and treat later” using proactive de-escalation techniques • Our “success” in assisting during an upset is usually related to our history of interacting prior to the upset

Some “Simple” de-escalation techniques

• Response Priming • Reflect and Reassure • Stimulus Change • Interspersed Requests • Focused Redirection • Topic Dispersal • Functional Replacement/Personal Intervention • Behavioral Momentum • Reinforcer Recall

#7. Understand the purpose of your help

• What is our specific programmatic mission?

• What is your personal reason for being here?

• How does this match with the preferences/desires of the person we are attempting to assist?

• Is there a general “purpose” that we can all agree to?

#7 Understand the purpose of your help

• To interact in a way that could produce greater autonomy, independence, inclusion, relationship, or social capacity for the person being helped • To interact in a way that affords more choices or quality of life to an individual • To interact in a way that invites greater participation regardless of the current context and regardless of the current or ultimate level of autonomy expected in that context…FUNCTIONAL OUTCOME • To interact in a way that embodies the five components of PEARL

Functional Area Outcome Menu (FAOM)

• Residential Status • Level of Independence • Behavioral/Emotional Status • Community Participation • Level of Awareness • Vocational Endeavors • Educational Endeavors • Involvement in Vocational or Educational activity • Level of Self-Managed Health • Intimacy/Relationships • Quality of Life

All ABI NeuroRehabilitation

Admit Discharge 1 Year Followup

Functional Measures

Are there specific ways of interacting that...

• Are effective?

• Are in sync with contemporary beliefs and practices?

• Can be taught in a replicable way?

• Can be evaluated when they are used?

Adapted from The Helping Exchange: PEARL (McMorrow, 2005, LASH Publishing)

POSITIVE

What does a positive action look and sound like?

P

ositive

• Upbeat • Greeting people when you see them • Pleasant tone of voice • Interested facial expression • Requesting or inviting action, rather than demanding it • Presenting as though one is interested in interacting or providing assistance • Looking like you are ready for work

EARLY

What would “early” mean in terms of providing assistance?

E

arly

• Not “waiting” around for upsets or risky situations to get worse • Intervening “early” to encourage use of desirable problem solving skills • Catching people early in a sequence of behavior that may lead to unwanted behavior • Using “antecedent-based” interventions to teach wanted behaviors • Being responsible when we see that others need assistance

ALL

In terms of providing assistance to others, what would the word “all” refer to?

A

ll

• Interacting with

all participants

(not just those who may be the most fun to be with) • Interacting

all the time

• Interacting in

all environments

* *Proactive Treatment Interaction can take place all day long, as different situations arise we can teach “on the go.” “Every interaction is an opportunity to teach.”

REINFORCE

What does the term “reinforce” mean with respect to the interactions we have in a human service context?

R

einforce

• A reinforcing interaction increases the future probability that a behavior will occur in a particular situation • “Reinforcers” are not the same for every individual • We have to discover what interactions will serve as a reinforcer for a particular individual • We can’t follow our “beliefs” about what should act as a reinforcer (our beliefs may be wrong) • We need to strengthen the likelihood of desired actions when the going gets difficult for those we assist

LOOK

What are you “looking” for when you are involved in human service?

L

ook

• “Listen” with all your senses (eyes, ears, nose, touch) so that you are always aware how the participant is doing • Look for opportunities to increase independence, autonomy, or inclusion wherever they may arise • Look for opportunites to teach the participant more desired ways to interact with his or her social and physical environment

Five Components of Proactive Treatment Interaction

P

= Positive

E

= Early

A

= All

R

= Reinforce

L

= Look Proactive Treatment Interaction

The PEARL Scale*

• Use as a “self evaluation” tool (e.g., how are you doing today?) • Use in peer evaluations (e.g., how well do your co-workers think you use PEARL?) • Use in supervisor evaluations and performance appraisals *Participants should be provided copies of the scale to review

Concept #8 Achieve and Share the Joy of our Work

• Why are you here doing this work?

• What are some of the things that you particularly enjoy?

• How often do you notice that the work makes you feel particularly good?

• How often do you let others know that?

• Can you learn to point it out when you see your co workers experiencing “joy” at work?

• Don’t let the “tough guys” make the rules • Everybody just does the best they can when the going gets difficult

You are ready to help when you can...

1. Refrain from doing any harm 2. Resist blaming people for the things they do 3. See interactional reciprocity at work in your life 4. Create mutually reinforcing relationships with those you assist 5. Teach in ways that empower (PI Plans) 6. Bounce off the upsets (Simple De-escalation) 7. Understand the purpose of your help (FAOM & PEARL) 8. Experience and share the “joy” of your efforts

How are you going to help?

Related Readings

McMorrow, M.J. (2003). Getting Ready to Help: A primer on interacting in human service. Paul Brookes Publishing, Baltimore, MD.

McMorrow, M.J. (2005). The Helping Exchange: PEARL. Lash & Associates Publishing and Training, Wake Forest, NC.

McMorrow, M.J., Braunling-McMorrow, D.L., & Smith, S. (1998). Evaluation of functional outcomes following proactive behavioral residential treatment. Journal of Rehabilitation Outcomes Measurement, 2(2), 22-30.

McMorrow, M.J., Guercio, A, & Guercio, J. (1998). Interacting with persons who are confused and agitated. Brain Injury Source, 2, 32-45.

McMorrow, M.J., & Braunling-McMorrow, D. (2001). Promoting Independence: Barriers and Possibilities. Brain Injury Source, 5, 8-10.

Condeluci, A. & McMorrow, M.J. (2002). Philosophy of Rehabilitation. Assoc. for Accreditation of Brain Injury Specialists, AACBIS Training Manual, Chapter Two, (2nd Edition) *email = [email protected]