There’s Always Something that Works: Evidence for the Importance of Optimism, Hope & a Sense of Humor When Supporting Individuals with Difficult Behavior.

There’s Always Something that Works: Evidence for the Importance of Optimism, Hope & a Sense of Humor When Supporting Individuals with Difficult Behavior Tim Feeney, Ph.D. Executive Director Petonbowk Academy Transitional Services for Youth and Famillies 1 Mill Street, Suite RL 29 Burlington, VT 05401 tim@tsyf.org

General Orientation  I talk fast, so please slow me down if I’m not making sense.  I have a sense of humor which can be off- putting, if I offend you, please let me know; an while it might be hard to believe, while I laugh and joke, please don’t misconstrue my humor for lack of seriousness.  I swear. A lot. If it’s too much, then just let me know and I’ll not swear.

Applied Behavior Analytic Approaches Baer, Wolf, Risley, 1987; Kantor, 1959; Skinner, 1953; Tharp & Wetzel, 1963 Setting Events & Establishing Operations Fox & Conroy, 1995; Michael, 1982;1993 Daily Routines/ Picture Routines Bondy, 1995 ; Koegel & Koegel, 1997; Wetzel & Hoschouer, 1984 Positive Behavior Supports Carr et al, 2002; Horner et al., 1990 Communication-BasedIntervention Carr et al., 1996; Durand, 1990; Reichle & Wacker, 1993 Socially Co-constructed Narratives Hudson & Fivush, 1993 Functional Behavior Assessment Carr & Durand, 1995; Iwata et al., 1994 Dynamic Assessment Feurerstein, 1979 Apprenticeship in Thinking Rogoff, 1990 Socially Mediated Cognitive Approaches Vygotsky, 1932; 1987 Planning Friedman & Scholnick, 1998 PERSON-CENTERED,CONTEXT-SENSITIVE,SELF-REGULATORYINTERVENTION Generalization & Maintenance Carr et al., 1990; Dunlap, 1996 Self-Regulation & Belongingness Baumeister & Vohs, 2003; Mischel, 2001 Self-Determination/ Motivation Theories Deci & Ryan, 2002 Situated Cognition Greeno, 2004 AnEvidence-Based,Integrated Approach to Intervention

Specific Evidence to Support Context-Sensitive Self-Regulatory Intervention

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

Context-Sensitive Structured Flexibility Context-sensitive means pre-planned and collaboratively developed scripts are used in the actual settings where the individuals are expected to participate; Structured flexibility means the individuals who are providing the intervention were trained and encouraged to adjust the specificity of the scripts and interventions to the needs of the individual and the requirements of the tasks, not to simply repeat the same scripts over-and- over; Self-regulation means identifying actions that are used to guide thinking, emotions, and behavior required to succeed in a given setting or for a given task

 What’s the meaning? Where’s the meaning?  Is this a can’t do? A don’t do? A won’t do?  What’s the individual’s chronological age? Behavioral age? Social age? Cognitive age?  How can we be therapeutic and forget about “therapy”?  What’s the short term goal? The long term goal?  Is this a me problem? A you problem? A we problem?

GOAL OF INTERVENTION  The individual not only behaves in ways that are acceptable, but CHOOSES to behave in ways that are acceptable  Thus the development of self-regulation is inevitably part of all supports.  The intervention is accomplished with as little failure as possible

Success supporting people with complicated needs requires movement away from a diagnostic (e.g., disability/impairment) approach to intervention to a functional approach to intervention and support Effective Support is About Creating Meaning MEANINGFUL THINGS WORK

WRONG QUESTION: What is the primary diagnosis? RIGHT QUESTION: What do we need to do to help this person find or create meaning in his or her life?

Common Themes of All Successful Interventions Intervention must be delivered early andIntervention must be delivered early and intensively, through established routines, and focus on the development of self-regulation and problem-solving strategies in context. In the absence of meaningful engagement in In the absence of meaningful engagement in chosen life activities all interventions will ultimately fail. Long term, flexible, and frequently adjustedLong term, flexible, and frequently adjusted supports may be needed to prevent behavior problems and to facilitate social development.

Goal Plan Do Review Predict

We’re in the Risk Business  What’s the worst that could happen? There is dignity in taking risks.  Anything short of someone getting hurt is often worth the risk.  But we don’t take risks in isolation. We think about it, talk with everyone about it, then take the risk in a planned manner with the support of others.  “Every good thing we do stands on the razor’s edge of disaster.”

In an Evidence-Based World What is Evidence?

The Point Just because we think it’s the best thing to do and we have evidence to support the interventions that we recommend, it doesn’t mean the people will do it! Interventions must be meaningful to each person, each family member, each clinician and connected to the pragmatics of day-to-day living.

A General Orientation to Managing Difficulties Resolve Resolve: Review What Happened Review What Worked/ Didn’t Work Make a Plan Return/Restore Return/Restore: Identify a Specific Action Include the “Target” Make a Plan for Similar Situations Respond Respond: Manage Difficulties Make an Immediate Plan Manage the Environment

A MEANINGFUL LIFE  #1: For humans here on earth, living is the everyday construction of meaning within relevant communities and in the presence of facilitators and barriers to the construction of meaning  #2: Rehabilitation workers are consultants to the individual’s construction of meaning!!  Embracing this philosophy yields as a corollary the acceptance of a collaborative approach within teams and with individuals with disability.

In an Evidence-Based World What is Evidence?

SocialCompetence Self-Regulation of Behavior SustainedPositiveOutcomes A Conceptual Shift: From “Teaching Skills” or “Increasing Knowledge” to Developing Competence in the Use of Skills and Knowledge

Context Relevancy: How does this stuff apply to the bigger world? adapted from Sailor, 1999 Useful: Useful: Do the outcomes that we’re targeting produce something useful to the individual in long run? Desirable:Desirable: Does the individual choose the outcomes for him/herself when given the choice? Is the individual given thechoice of outcome? Social: Social: Do the outcomes result in behaviors that will increase interactions with persons other than paid staff? Practical:Practical: Will the behavior be used in real contexts without staff support? Adaptable:Adaptable: Is there a focus on developing skills that can/will be used in a number of situations and without staff?

An Unspoken Reality  Once you enter any kind of hospital or rehab or helping setting, you lose your identity. You’re not Bob or Sue, you’re a “client” or a “patient”. You often lose your sense of self as a result of your injury and we often expedite your loss of self by the way we behave. So, in many ways it is our collective responsibility to behave in ways that are sensitive to these realities and to alter our behaviors so we don’t make the loss of self inevitable.

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 - Charles Sherrington, 1946 The Integrative Action of the Nervous System

SENSE OF SELF FOR INDIVIDUALS WITH CO- EXISTING 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

“The self is not something ready made but something in continuous formation through choice of action.” - John Dewey

An Identity Map Reconstructing/Constructing Identity POSITIVE IDENTITY METAPHOR FACTS FEELINGS APPEARANCE GOALS PROCEDURES What has this person done? What does this person look like? How does this person feel? What will I need to do? What am I trying to accomplish?

Goals: Simply comply Others set goals No goals for self Feelings: Anger at driver and all authorities Inadequacy, dependence Hopelessness, frustration Action strategies: No need for strategies; others take responsibility No sense of responsibility Other people’s charge Appearance: Crutches, casts, etc People Therapists, physicians, aides Places Hospitals, clinics Facts: TBI: 1991 Many injuries 11 weeks: hospitalization Casts, scars, crutches Multiple surgeries Jason the Victim

Goals: Freedom Independence Retribution (driver, any source of control) Victory!!!! Feelings: Anger/Oppression Power/Control Competence/Independence Zeal for justice Action strategies: When provoked, scorched earth policy Demonstrate ability and power Demonstrate others wrong Experiment with new things Try therapy (unsuccessful) Appearance: Attempt to project power People Everyday people Places Everyday places Facts: Former marine (Exaggerated) sense of Improvement Disjointed life in disarray Jason the Marine

Goals: First rate production Make a clear statement Define self Feelings: Satisfaction Accomplishment Growth Control Focus Action strategies: 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 Appearance: Appropriate to the context People Support people Non-conflict people Places Facts: Actor willing to be directed Director Mayor Producer Successful Clint Eastwood

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.

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

Common Sense Examples of Approaches to Establishing a Community  Rituals of Greeting/Checking In  Entering an interaction  Entering a building, a room, someone’s house  Rituals of Leaving/Checking Out  Leaving an interaction  Leaving a building, a room, someone’s house

THERE’S ALWAYS SOMETHING THAT WORKS: TALKING AND THINKING COLLABORATIVELY WITHIN COMMUNITIES OF SUPPORT

“Much of our cognitive life may be the product of highly automated routines.” - Gerald Edelman

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)

 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

The Point: We often teach a skill or set of skills independent of the realities of life that each person faces. While people might learn the skills and demonstrate mastery of skills these are meaningless unless we help them achieve competency in the use of the skills. In absence of competence use, skills are useless.

The Point In many (most?) situations, it is the quality of the relationship that you have with the individual which will have the greatest effect on the success of the intervention.

 With meaning comes the opportunity to have fun, and fun is therapeutic. With fun comes optimism, and optimism is therapeutic. With optimism comes hope, and hope is essential to pushing through the difficulties. With hope comes meaning...

54 The Importance of Optimism  “There’s always something that works”  Many people – especially those who have had a hard time in life (school, social life, work) do NOT believe that there is always something that works  Effectively strategic people DO believe that there is always something that works  Therefore optimism is a critical component of the SR scripts for many people

 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. Teaching a Learning How to Think

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.

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 student and 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

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”

Self-Regulation: Intervention Range of options: highly confrontational to non- confrontational. The degree of confrontation that is appropriate depends on:  length of time post injury  seriousness of the consequences of unawareness  severity of anosagnosia/potential for change  emotional fragility  age/maturity  available resources and support  environment

66 “Automatizing” SR/EF  Effortful self-regulation strategies: slow, attention and capacity consuming, relatively difficult to access, subjectively uncomfortable  Automatic self-regulation strategies: fast, not attention and capacity consuming, easy to access, subjectively comfortable  ex: Seat belts  From effortful to automatic/comfortable:  Point-of-participation practice  Success  Association with compelling sense of self

67 VYGOTSKY: MAIN POINTS 1. Cognitive growth as internalization/ appropriation of well-conceived interaction 2. Dynamic assessment to identify Zone of Proximal Development – not too easy, not too difficult 3. Teaching as mediated and “scaffolded” participation in valued activities 4. Gradual reduction of supports as the individual gains competence

68 PERFORMANCE-ORIENTED TEACHING (Ineffective When Teaching Self-Regulation) CONTEXT  Training context – not associated with the daily life one has or is planning outside the training context.  Performance demanded by others  Solo performance  Hierarchical organization of tasks

69 PERFORMANCE-ORIENTED TEACHING TASK STRUCTURE  Model (teacher)  Performance demand  Performance (student)  Reinforcement OR cues, prompts, simplification, etc  Repeated practice  Transfer procedures

70 APPRENTICESHIP TEACHING (Most Effective When Teaching Self-Regulation) CONTEXT  Natural context; perhaps projects with a meaningful goal  Social, collaborative activity  Success due to collaboration  Non-hierarchical organization of tasks

71 APPRENTICESHIP TEACHING TASK STRUCTURE  Engagement in guided observation  Collaborative, goal-oriented work, with supports as needed  Learner contributes as possible  Ongoing coaching, encouragement, modeling, brainstorming, etc.  Supports systematically withdrawn  Transfer guaranteed because of context and procedures

An impulse is not a choice

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!

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

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 choiceFree choice Fixed choiceFixed choice Forced choiceForced choice Feeling the natural and logical results ofFeeling the natural and logical results of actions in the environment

So, what are you doing? Why are you doing that? How’s it going? Is this helping? Not Helping? What are you hoping to achieve? What else can you do? What’s your plan? Some Scripts That Will Help You Figure Out if This is Really A Choice

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

86 SPECIFIC SR/EF SCRPITS: FORMAT  Identify the issue  State a reason  Generate a strategy  Offer general reassurance: “There’s always something YOU can do to make it work”

87 EXPERIMENT SCRIPT “THIS WAY OR THAT?”  Identify issue or conflict  Try both ways  Identify most successful  General reassurance

88 PROBLEM-SOLVING SCRIPT  Identify issue or conflict  State the reason  Generate a solution/strategy  General reassurance

89 HARD TO DO/EASY TO DO SCRIPT  Identify task as hard or easy  State the reason  Generate a strategy (if hard)  General reassurance

90 READY/NOT READY SCRIPT  Identify ready or not ready  State the reason  Generate a plan (if not ready)  General reassurance

91 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

92 “Play to Change Plays” SCRIPT  Identify the issue: Change or deviation from routine  State the reason  Generate a strategy (e.g., ask for help)  General reassurance

93 SCARY/NOT SCARY SCRIPT  Identify situation as scary or not scary  State the reason  Generate a solution/strategy  General reassurance

94 MY DEAL/YOUR DEAL SCRIPT  This is my deal (or your deal)  It’s my deal because  Because it’s my deal, this is what I will do…  There’s always something that works

95 WHAT ABOUT YOU? SCRIPT  It’s important to know what John thinks/John feels  It’s important because...  Here’s a way to find out...  There’s always something that works

FUN IS NOT:  Worrying about being politically correct  Going to “therapy”  Doing a workbook activity  Working on fricatives in the speech closet  Working to meet some fricking criterion on some fricking test before I can get out of this fricking place  Being told to “be realistic”  Being told to “be realistic” by some snot- nosed 24 year-old who hasn’t lived life like I have

FUN IS:  The 1st time  Kids  Play  Joking  Friends  Watching the Cats win!  Laughter  Hope  Feeling connected  Feeling useful  Viagara  Being naughty  Love  Pure joy  Doing something you really like with someone you really like  Accomplishing something meaningful

MINDSETS NOT CONDUCIVE TO FUN:  The Oprah Type - victim/tragedy/altruist Typical utterances: Typical utterances: “Suffers from...” “Victim of...”  The Dr. Kildare Type - medical orientation Typical utterances: “The patient...”  The Dr. Phil Type - control/territorial Typical utterances: “You gotta...” “We tried that before, it’ll never work” “Because I’m the expert” “This is my area, don’t mess with me!”

MINDSETS CONDUCIVE TO FUN:  Flexible Typical utterances: “Yeah, we can do that.” “That looks interesting, different than I thought but it’s worth a try.” but it’s worth a try.”  Collaborative Typical utterances: “Whaddaya think?” “Geez, that’s a good idea, let’s give it a shot.”  Mature Typical utterances: “You’re right!” “Some things I can’t change.”

MINDSETS CONDUCIVE TO FUN: Risk taking Typical utterances: “Well, I don’t know what might happen...” “What’s the worst that could happen?” “What’s the benefit?” “Sometimes it’s easier to ask for forgiveness than for permission” than for permission” Hopeful Hopeful Typical utterances: “Hey, we’re onto something here!” “Let’s give it a shot.” “Sure, we can do that.” Self-EffacingSelf-Effacing Typical utterances: “I don’t think I could think like that.” “I couldn’t ever.”

FUNCTIONAL does not equal Increased/Improved performance on standardized tests

FUNCTIONAL does not equal Bowling or the The Friday Outing or the The really neat, really expensive, simulated...

FUNCTIONALequals Creating stable routines of life that enable me to do what I need to do when I need to do it.

Fundamental Premise #1 Living is an ongoing process of constructing meaning out of the diverse units of experience that life throws our way

Fundamental Premise #2 Rehabilitation providers are collaborative consultants to the process of constructing meaning in life. We collaborate with:  Individuals with disability  Significant people in their lives (e.g., family members)  Our colleagues from across the professions and across the “ranks” of workers  Anybody who can make a difference

Fundamental Premise #3 Intervention providers will forever be unsuccessful or unhappy collaborators as long as they define themselves as  Molly the surgeon  Molly the animal trainer  Molly as an Oprah-like sympathizer  Molly as mommy  Other Fortunately it is possible to construct an identity as a collaborator – and live happily ever after!

What is Collaboration?  Collaboration is an ongoing creative process in which two or more people work together toward a common goal that is difficult to achieve working in isolation  The collaborators commonly bring diverse competencies to the collaboration  The collaborators have some overlapping goals/interests and some distinct goals/interests  “Leadership” is primarily via competence versus authority roles  Collaboration is not “I love you! You love me! We all love Barney” – but rather requires mature self-regulation and respect

What is the Value of Collaboration?  Demonstrating respect for others  Acquiring others’ perspectives (all others)  Learning while doing: others’ skills/perspectives  Teaching while doing: ones own skills/perspectives  Increasing creativity in problem solving  Intensifying services and supports: efficiency  Increasing consistency of services and supports  Coordinating – preventing fragmentation  Facilitating generalization and maintenance  Infusing reality, common sense, functionality

Value: Breakdown  Collaboration with colleagues  Communicate respect  Integrate and intensify services  Learn from each other  Heighten creativity  Collaboration with individuals with disability  Communicate respect  Teach using apprenticeship procedures  Learn their perspective  Collaboration with significant others  Communicate respect  Integrate and intensify services  Acquire a real-world perspective

Human service providers are like everybody else in that they:  Like some people and don’t like others  Get along with some people and don’t get along with others  Can be defensive and territorial when stressed  Can get really angry at people who create obstacles to their achieving their professional goals  Have a sense of professional/worker identity that yields emotional reactions to professional situations and often dictates behavior  Can even be upset with the people they are paid to serve  Cannot be expected to control all of their emotions, but CAN be expected to control their thinking and behavior in the interest of their fundamental mission

What’s the Point??  All interventionists have at least one and probably several “identities” as a professional.  If none of these identities fits with the “collaborator identity”, then collaboration (with co-workers, clients, families) will feel foreign, uncomfortable, undesirable  But identities can be shaped – and professional identity construction may be required

So Many of Us Have a Sense- of-Humorectomy We spend our lives with interesting people doing interesting things! Look at the fun side of things! What’s the big deal? Embrace the chaos!

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, common- sense, 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.

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, self-monitoring, problem solving  Observe effects of real-world supports and routines  Observe support behaviors of others

120 The Importance of Optimism  “There’s always something that works”  Many people – especially those who have had a hard time in life (school, social life, work) do NOT believe that there is always something that works  Effectively strategic people DO believe that there is always something that works  Therefore optimism is a critical component of the SR scripts for many people

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.

So, why is self-regulation so important?

123 EXECUTIVE FUNCTIONS “… those mental capacities necessary for formulating goals, planning how to achieve them, and carrying out the plans effectively” (Lezak, 1982) “…ability to maintain an appropriate problem-solving set for attainment of a future goal.” (Welsh & Pennington, 1988)

124 Self-Regulation “Using thought to guide behavior” (L. Berk) “Self-regulation refers to the many processes by which the human psyche exercises control over its functions, states, and inner processes.” Vohs, K.D., & Baumeister, R.F. (2004). Understanding self- regulation: An introduction. In R.F. Baumeister & K.D. Vohs (Eds.), Handbook of self-regulation: Research, theory and applications (pp. 1-9). New York: Guilford Press.

125 Self-Regulation “Using thought to guide behavior” (L. Berk) “Self-regulation refers to the many processes by which the human psyche exercises control over its functions, states, and inner processes.” Vohs, K.D., & Baumeister, R.F. (2004). Understanding self-regulation: An introduction. In R.F. Baumeister & K.D. Vohs (Eds.), Handbook of self- regulation: Research, theory and applications (pp. 1-9). New York: Guilford Press.

Self-Regulation and supporting individuals in the development of self-regulatory behaviors cannot be implemented as stand-alone or an independent “curriculum” separate from everything else; self-regulation, is integral to long term success in life, and is foundational to effective intervention all Domains of rehabilitation and learning.

The Bigger Point: Self-regulation and achievement are inseparable Managing my attention increases my success academically, vocationally, socially, behaviorally; Managing my emotional state improves my ability to do the hard stuff; Being organized (cognitively) helps me to remember what I’m learning and use what I have learned when I need it; Working together positively improves my overall performance.

128 EF/SR: Theory Construction R. Barkley Primary: Behavioral Inhibition Working Memory: Nonverbal Internalization of Speech: Verbal Working Memory Self-regulation of affect, motiv -ation, arousal Reconstitution: Creativity, organization Motor control/fluency/syntax Inhibition of task-irrelevant responses Execution of goal-directed responses Sensitivity to feedback Flexibility, etc.

PERSON Mental Health Cognition LanguageEmotionVolitionBehavior Human beings are a collection of relatively independent structures, processes, and systems

John’s Cognition AttentionPerceptionMemoryOrganizationReasoningEF Arousal Select Direct/ Filter Maintain Divide Shift 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 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 IAxis IIIAxis IIAxis IVAxis V Personality Disorders Mental Retardation General Medical Conditions Global Assessment of Functioning Goals for John: John will 1.Participate in psychotherapy sessions without falling asleep 2.Comply with his medication regimen as directed 3.Follow the recommendations of the clinical staff to assure his safety 4.Seek community services for his disorder and for his living arrangements Clinical Disorders Other Conditions Psychosocial And Environmental Problems

John’s Behavior 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 John is the totality of his behaviors and the systematic relationships among them

Alternative Understanding of Human Beings Sarah Pursuing personally meaningful goals While participating in culturally valued activities Using cultural tools, such as language, category schemes, mathematics, organizational supports, domain-specific strategies Mediated as necessary by individuals with greater expertise in that domain In social, cultural, and historical contexts In the presence of varied context facilitators and barriers

134 EF/SR Organizing and controlling action, thought, and emotion in a way that is (1) not determined by immediate environmental events, (2) not determined by immediate impulse or states of the body, (3) not determined by the control of others, (4) directed toward personal goals, (5) while taking into account environmental factors such as the goals and intentions of others  Conscious/effortful OR automatic/habitual

135EF/SR  “COLD”: Self-regulation of covert cognitive and linguistic processes  Associated with dorsolateral prefrontal cortex  e.g., working memory tasks  “HOT”: Self-regulation of emotions and observable social behavior  Associated with orbital and ventromedial prefrontal cortex  e.g., delayed gratification tasks; “gambling” tasks  Interact in the real world – despite neuroanatomic and neuropsychological separability Denckla, 1996

136 EF/SR: UNORGANIZED LIST  Setting and managing goals  Planning  Organizing  Initiating  Inhibiting  Self-monitoring  Strategic thinking  Problem solving  Working memory  Flexible shifting  Deliberately controlling any cognitive  Delaying gratification  Social perception  Controlling emotions  Learning from consequences  Organized sense of self

137 Facilitation of Nonconscious/ Automatic Self-Regulation  Internalized EF scripts habitually associated with specific environmental conditions  Internalized sense of self essentially connected to self-regulatory strategies habitually associated with specific environmental conditions Thus, for people who are “stimulus bound” due to their disability or their personal histories, the environment becomes the stimulus for nonconscious self-regulation (or, without the right supports in place nonconscious NON- regulation)

138 Illustrations of Nonconscious/ Automatic Self-Regulation  Investigators have shown that people placed in positions of power tend to pursue goals and use strategies that they associate with power, without being aware of the source of the goals or strategies.  Similarly people have been shown to pursue goals and implement strategies associated with specific people (e.g., family members) when primed with a representation of that person (e.g., WWJD)

139 Nonconscious Self-Regulation “Goals can be primed and activated by environmental cues outside of awareness. Once activated, these goals can enhance performance, persistence in the face of failure, and the resumption of disrupted goal-directed behavior in the presence of alternatives.” p. 198 Cervone, D., Mor, N., Orom, H., Shadel, W.G., & Scott, W.D. (2004). Self-efficacy beliefs and the architecture of personality. In R.F. Baumeister & K.D. Vohs (Eds.), Handbook of self-regulation: Research, theory and applications (pp. 188-210). New York: Guilford Press.

Simple Rules of Apprenticeship Interactions  Think: Repeated conversations focused on self-regulation scripts (big deal – little deal, etc.)  Collaborative – Elaborative conversations  Establish a goal (as simple and basic as you need) and then demonstrate/reflect on whether what you are doing is addressing that goal – if yes, continue, if no, then try something else  Wait!

141 POSITIVE INTERACTION STYLE: COLLABORATION  Intent (Goal)  Cognitive support (Filling in the blanks or clarifying confusion)  Emotional support (Optimistic focus on what can be done, and acknowledging upset and difficulty)  Meaningful, supported questions (You think that’ll help? Anything I can do?)  Collaborative turn taking (This is going to be hard, how can we work together on this?)

142 POSITIVE INTERACTION STYLE: ELABORATION  Topics  Elaborative organization  Elaborative explanation

Reasons Why People Don’t Choose to Plan When They Could Adapted from Ellis & Siegler, 1997 Planning requires delay in attaining goals and Planning requires delay in attaining goals and the impulse for immediate gain is stronger than the impulse for immediate gain is stronger than the choice to delay an action the choice to delay an action Planning requires the suppression of currently Planning requires the suppression of currently activated behaviors activated behaviors Individuals are often overly optimistic about their Individuals are often overly optimistic about their success in the absence of planning, reducing the success in the absence of planning, reducing the perceived need for planning perceived need for planning Planning takes time, and speed is often valued Planning takes time, and speed is often valued over accuracy over accuracy

Reasons Why People Don’t Choose to Plan When They Could Generating plans is no guarantee of success and 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 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 An individual may assume someone else will make a plan for him/her It’s often exciting NOT to plan It’s often exciting NOT to plan

Helping People Choose to Plan DO NOT plan on planning in situations that have DO NOT plan on planning in situations that have historical impulsive routines in place historical impulsive routines in place Help individuals to “connect the dots”; make the Help individuals to “connect the dots”; make the outcomes associated with planning explicit and outcomes associated with planning explicit and the likely outcomes associated with not planning the likely outcomes associated with not planning equally explicit equally explicit Show the positive effects of planning for the Show the positive effects of planning for the individual in the short term and long term individual in the short term and long term

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. 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.

153 EVERYDAY ROUTINES OF INTERACTION Everyday routines associated with the contexts in which one finds him or herself should be organized in such a way that the individual is engaged, as much as possible and with needed supports, in the executive dimensions of everyday activities.

154 THEORETICAL SUPPORT: VYGOTSKY “Higher mental functions evolve through social interactions with adults; they are gradually internalized as the child becomes more and more proficient and needs less and less cuing and other support from the adult.”

155 SELF-REGULATION  Within the Vygotskyan tradition, the development of self-regulation is understood as the gradual internalization/appropriation of well-conceived routines of adult-child interaction. Initially, regulation exists as adult regulation of the child. Gradually, the child practices overt spoken regulation (of dolls, pets, peers, etc.), then spoken self-directed regulatory talk, and finally covert self- regulatory “talk”.

Interaction Scripts for Routines Making Decisions Making Decisions About the Goal About the Goal “What’re you going to do?”“What’re you going to do?” “What are we here for?”“What are we here for?” “How will we know we’re done?”“How will we know we’re done?” “We’ll know we’re done when“We’ll know we’re done when it looks like this... “

Making Plans Making Plans “OK, so what’s the plan?”“OK, so what’s the plan?” “What’ll you need to get this done?”“What’ll you need to get this done?” “How will you and I know you’ll“How will you and I know you’ll need help?” “What will help look like?”“What will help look like?” “Don’t tell me what you don’t “Don’t tell me what you don’t want, tell me what you do want.” “OK, so what do you want me to do?”“OK, so what do you want me to do?”

Making Decisions About Ease or Difficulty Before Beginning Difficulty Before Beginning “Do you think this will be hard or easy?”“Do you think this will be hard or easy?” “If it’s hard, then what’ll you need?”“If it’s hard, then what’ll you need?” “Have you ever done this before?“Have you ever done this before? What happened? “I don’t think I could do this! How do“I don’t think I could do this! How do you know that you can?” “Whaddaya think? Big deal or little deal?”“Whaddaya think? Big deal or little deal?”

Coaching Through Problems “You look upset, is there anything“You look upset, is there anything I can do?” “OK, you’re not ready. No problem;“OK, you’re not ready. No problem; just let me know when you’re ready. “I’ll know you’re ready when you“I’ll know you’re ready when you look like this...” “I’ll wait.”“I’ll wait.” “You know we’ve gotta figure this“You know we’ve gotta figure this out, let’s try... “ “I know it’s hard, but we’ve got“I know it’s hard, but we’ve got to do this.”

Coaching in Context “So, how’s it going?”“So, how’s it going?” “Is that helping you? Not helping?”“Is that helping you? Not helping?” “Is there anything else you can do?”“Is there anything else you can do?” “Is there anything I can do to help you?”“Is there anything I can do to help you?” “So when are you going to start?”“So when are you going to start?”

Review What Occurred Review What Occurred “So how’d it go?”“So how’d it go?” “How’d you do?”“How’d you do?” “Tell me exactly what happened...“Tell me exactly what happened... and then what?” “What do you think other people“What do you think other peoplethought?” “What were you thinking when you...”“What were you thinking when you...” “Next time you do this, what’ll you do “Next time you do this, what’ll you do differently? The same?” “What helped?“What helped? “What didn’t help?”“What didn’t help?”

Themes 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 self- regulation 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

Sensory Integration and Behavior TOUCH Skin Pacinian Corpuscles Vagus Nerve Reduction of Cortisol Increase in Cortisol Increase in Oxytocin Decrease in Oxytocin Improved Affect Negative Affect

Getting Staff On Board We must share a basic philosophy of what it is to live as a human being and what role we play in helping others achieve meaning in their lives

Scripts of Collaboration for Tough Situations  Situation:  Impulse:  Self-regulated collaborator script:  Memo to self: “There’s always something that works!!”  Whatever my emotions, I need to  Take a long view  Remain optimistic  Remain focused on the point of this whole enterprise: to help individuals to participate meaningfully and successfully in activities of their choosing within contexts of their choosing

Scripts of Collaboration for Tough Situations  Situation: Team member questions your professional role or competence  Impulse: Rip his or her eye balls out of their sockets  Self-regulated collaborator script: This person struggles with insecurity. I will smile and do my job. Competent performance is my best communication. “I hear what you’re saying. Let me explain how I have come to this conclusion. And then let’s see if WE can focus on how best to help John with …. “  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Team member says that we can’t let the person do …..; his self-regulation is too impaired  Impulse: “He’s right; we need to maintain control”  Self-regulated collaborator script: “You’re right; we must be cautious. But let’s see what supports might be used to begin the process of inching towards independence. There are lots of steps here – just like with typically developing kids.” (experimental script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Team member agrees to a course of action, but doesn’t follow through  Impulse: Rip his eyeballs out; seek comfort of other team members. Vilification!  Self-regulated collaborator script: “Tom, it appears that you’re having a hard time with this. Help me understand. Do you think I’m making a big deal out of a little deal? What can we do to get on the same page?” (big deal/little deal and experimental scripts)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Team member honestly disagrees with your proposed course of action  Impulse: “I’ll force him to come around to my way”  Self-regulated collaborator script: “Alright; we disagree. How could we put our separate plans/proposals (hypotheses) to a test?” (experimental script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Team member questions your commitment or intentions  Impulse: “Intercourse you!” Spin and walk away  Self-regulated collaborator script: “Wow! That’s a hard one. I’m going to do my best not to sound defensive, but let me make my views and intentions clear. Then maybe you can do the same.” (What’s in my head? what’s in your head? script)  Memo to self: “TASTW!!” (and I can always call Guido later)

Scripts of Collaboration for Tough Situations  Situation: Student says, “This is worthless; I’m not getting anything out of this”  Impulse: “Look here, pal. Let me tell you why this is good for you. You listen to me and you listen real good.” OR just move on for fear of offending  Self-regulated collaborator script: “Sorry this seems like a waste of your time. Here’s why I think it might be worthwhile…. But maybe I’m wrong. Let’s see if WE can think of a little experiment to see if this is useful or not.” (experimental script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Student says, “This is going on forever. When will I be done?”  Impulse: “Let’s see if we can set a date – how about May 1 st ?” OR just move on for fear of offending  Self-regulated collaborator script: “I know it seems like forever. And I sure don’t want to waste your time. Let’s review; remind ourselves of what you are trying to accomplish, see where you’ve come. Let’s stick with winners; give up losers.” (G-O-P-D- R script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Student says, “When will I be all better?”  Impulse: patronize: “But you are getting better; and we’re all behind you!” or panic: “Do I dare tell him he’s not going to be all better?”  Self-regulated collaborator script: “I know this sucks; it really sucks! (Understanding script) But you know that this is a life sentence – not like a broken leg. BUT let’s decide what “better” looks like and how we can get to “better”. And you know, if we can figure stuff out, we can share it with others. (Project script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Student says, “I’ve got nothing to offer; I can’t be part of this project.”  Impulse: “Deep down I think he’s right; he needs so many basic skills before he can participate in a project.”  Self-regulated collaborator script #1: “But you know you’re not in this alone. We all will be working together. What you have a hard time with, I or somebody else can do. (collaboration script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Student says, “I’ve got nothing to offer; I can’t be part of this project.”  Impulse: “Deep down I think he’s right; he needs so many basic skills before he can participate in a project.”  Self-regulated collaborator script #2: “We’re going to be doing this to help people who are going through what you are going through. And you know that you are an expert – THE expert in what you are going through.” (motivational, self-concept script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Student says, “I don’t need your help. I can do it by myself.”  Impulse: Patronize “This proves that this guy really needs my help.”  Self-regulated collaborator script: Part 1: “Well you know that life for all of us is getting help when we need it. This isn’t a brain injury thing.” Part 2: “Great! Now, could you show me?” (experimental script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Family member continually excuses the inactivity or negative behavior of your client.  Impulse: “Don’t you see that you are an enabler?? He won’t get any better if you keep making excuses.”  Self-regulated collaborator script: “It’s tough to know exactly how to respond to John when he… I see why you would rather not …. But you know that there’s a potential downside to that too. Let’s see if WE can think of a way to…” (understanding and flexibility script; experimental script)  Memo to self: “TASTW!!”

Scripts of Collaboration for Tough Situations  Situation: Family member doesn’t agree with your approach.  Impulse: “Hey! I know what I’m doing! I’m a freaking expert! So get with the program here!”  Self-regulated collaborator script: “I understand that you see this differently. Let’s see if WE can think of a way to experimentally identify an effective approach. Perhaps we can try it both ways. And let’s try one thing one time.” (experimenter/collaborator script)  Memo to self: “TASTW!!”

WHAT WE’VE LEARNED OVER THE PAST 25 YEARS: PRINCIPLES GUIDING THE DEVELOPMENT OF SUCCESSFUL LONG-TERM SUPPORTS FOR INDIVIDUALS WITH MULTIPLE NEEDS

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

Medical/Expert Model: I set your goals I make your decisions “Shallow” Person-Centered: “Whatever you Say!!” “Mature” Person-Centered: Organize supports around goal- directed choices Thesis: External Control Anti-thesis: Enable Impulsiveness Synthesis: Facilitate goal- directed choice Apparently irresolvable conflict Goal-Directed Identity

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

“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

SENSE OF SELF FOR INDIVIDUALS WITH CO- EXISTING 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 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

An Identity Map Reconstructing/Constructing Identity POSITIVE IDENTITY METAPHOR FACTS FEELINGS APPEARANCE GOALS PROCEDURES What has this person done? What does this person look like? How does this person feel? What will I need to do? What am I trying to accomplish?

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!!

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

PRINCIPLE: 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

Context-Sensitive Structured Flexibility Context-sensitive means pre-planned and collaboratively developed scripts are used in the actual settings where the individuals are expected to participate; Structured flexibility means the individuals who are providing the intervention were trained and encouraged to adjust the specificity of the scripts and interventions to the needs of the individual and the requirements of the tasks, not to simply repeat the same scripts over-and- over; Self-regulation means identifying actions that are used to guide thinking, emotions, and behavior required to succeed in a given setting or for a given task

Helping People Choose to Plan Help the individual to make small/brief plans 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

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!

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”

ROUTINES Repetition creating temporal structure to improve memory Repetition creating temporal structure to improve memory about relevant past events about relevant past events Cognitive predictions about what happens next Cognitive predictions about what happens next Natural occasions for promoting cognitive growth Natural occasions for promoting cognitive growth An impetus for improvisation when trying to avoid An impetus for improvisation when trying to avoid a negative outcome a negative outcome are a necessary prerequisite forPlanning

197 EVERYDAY ROUTINES OF INTERACTION Everyday routines associated with the contexts in which one finds him or herself should be organized in such a way that the individual is engaged, as much as possible and with needed supports, in the executive dimensions of everyday activities.

ConcreteRoutines Picture Routines Picture Routines Written Routines Written RoutinesInteractionRoutines Language Routines Language Routines Activity Sequencing Activity Sequencing Routines to Deal with Changes in Routines What I do when what I expected What I do when what I expected to happen doesn’t happen to happen doesn’t happen

PRINCIPLE: COMPONENTS OF LIFE MUST BE INTEGRATED  Individuals who are fragmented should live within integrated systems of support  Domains of integration  Across everyday contexts: Clinical sessions – Across professionals and between professionals and everyday people  Across systems of care  Across the individual’s pre-injury and evolving post-injury sense of self

PRINCIPLE: ASSESSMENT IS ONGOING AND CONTEXT-SENSITIVE  Requirement of functional behavior assessment  Collaborative hypothesis testing  Engagement of the person in assessment  Assessment informs intervention/support informs assessment informs intervention/support informs assessment ……………………

The General Idea You’ve got an idea, I’ve got an idea, either one might work. Let’s test them out! Before we start, how will we know if something is working or not? We’ll stick with the winners and get rid of the losers

DYNAMIC ASSESSMENT ONGOINGCONTEXT-SENSITIVECOLLABORATIVEHYPOTHESIS-TESTINGASSESSMENT

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)

PRINCIPLE: BEHAVIORAL CONCERNS ARE ADDRESSED VIA POSITIVE BEHAVIOR SUPPORTS  Environmental focus: Aspects of the environment – settings, people, activities, demands – are primary contributors to behavior  Antecedent focus: Behavior plans largely focus on antecedents and are designed to facilitate success  Consequences are logical and meaningful  Skill development: Skills are developed to achieve meaningful goals

CONSEQUENCES ARE A-OK AND NECESSARY as long as they are: Immediate Natural Authentic Logical

Success via Learning from Consequences ConsequencesPresupposes: 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

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 all intervention to empower people to succeed with natural supports

PRINCIPLE: THE PERSON IS THE CORE OF ALL INTERVENTION AND SUPPORT EFFORTS  Participates in goal setting and planning  Is an integral contributor to the assessment process  Takes an active role in managing staff  Interviews and hires staff  Created a self-advocacy video  Developed house rules  “The management project”: Helping the person create an identity that is:  stable, positive, nondisability orientated, but inclusive of hard strategic effort  “The Manager”

PRINCIPLE: INTERVENTIONS AND SUPPORTS ARE ORGANIZED AROUND PERSONALLY MEANINGFUL ACTIVITIES Example: The “management project” is personally meaningful to the participant because he is participating in chosen life activities:  Community Outings  Critiquing management training videos with HCSS  Completion of meaningful tasks with HCSS  Teaching management training courses

PRINCIPLE: CONTEXTUAL SUPPORTS ARE CRITICAL TO SUCCESS Everyday people are oriented to a communication style that is:  Collaborative  Elaborative  Positive in offering constructive feedback

PRINCIPLE: REDUCTION OF SUPPORTS IS PART OF THE PLAN Focus of support plan:  Self-regulation  Self talk scripts Resulting in:  Reduction of negative behavior leading to the reduction of paid supports associated with increase in success with natural supports

PRINCIPLE: POSITIVE EVERYDAY ROUTINES ARE THE CONTEXT FOR PURSUIT OF MEANINGFUL GOALS  The participant and supports create routines daily  The participant, and supporters review routines and celebrate all attempts at adherence  Clinical “sessions” end with weekly routines that fill time with meaningful “management project” activities  Schedule includes ample celebration of planning, routine development, and maintenance of routines  Routines are flexible

PRINCIPLE: FEEDBACK IS CONTEXT- SENSITIVE 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

PRINCIPLE: COMPONENTS OF LIFE MUST BE INTEGRATED  Collaboration between providers  Collaboration with family members

PRINCIPLE: ONGOING CONTEXT- SENSITIVE ASSESSMENT  Functional behavior assessment  Collaborative hypothesis testing  Engagement of the person in the assessment process  Assessment informs intervention/support informs assessment informs intervention/support

There’s Always Something that Works: Evidence for the Importance of Optimism, Hope & a Sense of Humor When Supporting Individuals with Difficult Behavior.

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There’s Always Something that Works: Evidence for the Importance of Optimism, Hope & a Sense of Humor When Supporting Individuals with Difficult Behavior.

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