1. Contemporary Behavioral Approaches: Techniques and Results Debra Braunling-McMorrow, Ph.D. V.P. Development NeuroRestorative debra.mcmorrow@thementornetwork.com

3. PURPOSE Understand Contemporary Rehab. And Behavioral Themes Understand the importance of antecedent based approaches in responding to and preventing behavioral issues Understand Behavioral Sequences and the Importance of Windows of Opportunities in Providing Support Use Personal Intervention and Other Approaches Achieve Meaningful Outcomes

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

5. Where are people with brain injuries who have behavioral issues?…………

6. BRAIN INJURY AMONG THE HOMELESS MN Plan to End Long-Term Homelessness – Of 1,320 homeless individuals, 39% report possible BI. (Heading Home project April, 2008) Assessment of 100 homeless men in NY found 82% suffered brain injury in childhood, primarily as a result of parental abuse (Gordon, et. Al., 2006) 23% of homeless population are veterans – 47% Vietnam era – 67% served 3 or more years – 89% received Honorable Discharge (Interagency Council on the Homeless, 1999)

7. BRAIN INJURY AMONG PRISONERS Studies indicate TBI occurs among an estimated 25-87% of the jail and prison population (Walk. Helgeson, Langlois, Brain Injury Professional, 2008) In contrast, to an estimated 8.5% of non- incarcerated adults (Silver, et. Al., 2001)

9. SOME CONTEMPORARY THEMES IN BEHAVIORAL INTERVENTION Outcome Driven Proactive/Non-Intrusive Person Centered Self-Managed Interactional We all wear the hat of a behavior analyst

10. SOME BASES OF BEHAVIORAL INTERVENTION Thoughts, Feelings and Actions are “things” “Things” happen for a Reason… they are caused Sometimes we can change “things” We make decisions whether behavior is “good” or “bad” There are two main ways to change “things” (Stop old or Start new) Contemporary Themes influence Practice

11. APPROACHES TO BEHAVIOR CHANGE ONE WAYANOTHER WAY FocusSingle BehaviorComplex Sequence GoalReduce InappropriateIncrease Appropriate StyleReactiveProactive TimingConsequence (After)Antecedent (Before) IntentProvider ControlPersonal Control LocaleExcluded SiteIncluded Site PurposeManage BehaviorEmpower Participant FlavorImpersonalMutually Reinforcing

12. CHANGING BEHAVIOR Having an impact on the things that happened before or after behavior 1.Discouraging “old ways” of behaving after they occur (REACTIVE APPROACH) 2.Removing certain causes as behavior is happening (PASSIVE APPROACH) 3.Encouraging new ways of behaving when the causes show up (PROACTIVE APPROACH)

13. PREDISPOSITIONS We are all “predisposed” to behave in particular ways based on “what we bring with us” to a particular situation. Persons with ABI bring a complex combination of pre and post-injury factors. SOME PREDISPOSING FACTORS: Learning History, Medical Conditions, Medications, Neurological Status, History of Trauma, Substance Exposure, Treatment History, Sleep Deprivation, Interactional History, Emotional Backdrop, Environmental Stimulation, etc.

14. ANTECEDENTS Events that occur in some temporal proximity to the behavioral sequence of interest that are believed to play a causal role in their onset SOME POTENTIAL ANTECEDENTS: Difficult Tasks, Particular Individuals, Environmental Conditions (e.g., heat, clutter, noise, etc.), Presence of Desired Objects, Particular Interactions (e.g., criticism, public corrections, competition, etc.)

15. WHEN THE “HEAT COMES ON THERE ARE FOUR GENERAL WAYS THAT PEOPLE CAN RESPOND… 1.ESCAPE OR AVOID 2.WITHDRAY OR “FREEZE” 3.GET EMOTIONAL 4.PROBLEM-SOLVE ACTING ANY OF THESE WAYS MAY SERVE TO MAKE A DIFFICULT SITUATION LESS DIFFICULT THE PROBABILITY OF 1, 2, & 3 ARE IMPACTED BY AN INDIVIDUAL’S ABILITY TO PROBLEM-SOLVE

16. PERSONAL INTERVENTION AT A GLANCE HIGH LOW TIME AROUSALAROUSAL From McMorrow, 1994 NOW IS TIME FOR ACTIVE TREATMENT AND PERSONAL INTERVENTION NOW IS TIME FOR RISK MANAGEMENT An escalating sequence of behavior

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

18. STANDS AND COMMITMENTS OF A PROACTIVE APPROACH Emphasis on Positive/Mutual Reinforcement Avoidance of methods based on punishment, extinction, or escape-extinction learning operations Minimal medication regimen and no PRN’s Least restrictive treatment (no fooling!) No mechanical restraint or exclusive/seclusion Keep participants involved in the life of their community Treat all participants with respect and dignity (no matter what…) Include “stands” as a part of quality assurance measures

19. THEMES OF PROACTIVE REHABILITATION Create pathways to obtain preferences Establish “type 2” reinforce-reinforce reciprocity Establish problem-solving skills in difficult situations Increase probability of problem-solving by maintaining low arousal Graduate exposure to more difficult situations to enhance experience of success

20. INTERACTIONAL “DO’S” (interacting with confused and agitated) GET YOURSELF ORIENTED DEVELOP A CHARACTERISTIC INTERACTIONAL STYLE GRADUATE EXPOSURE TO ENVIRONMENT, OPPORTUNITIES, REHAB EXPECTATIONS ENCOURAGE SAFE EXPLORATION DISCOVER PREFERENCES LEARN TO “LISTEN” BOUNCE BACK QUICKLY FROM PROBLEMS REACH AGREEMENTS

21. RECIPROCITY GOES BOTH WAYS RECIPROCITY IS AN ONGOING EXCHANGE OF SIMILAR INTERACTIONS. (THERE ARE TWO TYPES OF RECIPROCITY) 1.ATTACK – ATTACK/NEGATIVE (“EYE FOR AN EYE”) 2.REINFORCE – REINFORCE/POSITIVE (YOU SCRATCH MY BACK AND I’LL SCRATCH YOURS)

22. Eye For An Eye Will Make the Whole World Blind Gandhi

23. COMPONENTS OF ACTIVE TREATMENT INTERACTION P Positive E Early A All R Reinforce L Look _________ PEARL McMorrow & Kirkpatrick, 94

25. SOME BEHAVIORAL DE-ESCALATION PROCEDURES RESPONSE PRIMING REFELCT AND REASSURE STIMULUS CHANGE (X2) INTERSPERSED REQUESTS FOCUSED REDIRECTION REINFORCER RECALL TOPIC DISPERSAL FUNCTIONAL REPLACEMENT BEHAVIORAL MOMENTUM

26. COMPONENT OF A PERSONAL INTERVENTION PLAN An individualized compensatory strategy for managing emotions and behavior in difficult situations LIST PREDISPOSING FACTORS LIST EVENTS OR ANTECEDENTS TO UPSETS IDENTIFY SEQUENCE OF UNWANTED BEHAVIOR LIST DESIRE REPLACEMENT BEHAVIOR IDENTIFY SUPPORT NEEDED FROM OTHERS

27. WHAT IS PERSONAL INTERVENTION? 1.An individual plan for managing one’s emotions and behaviors in difficult situations. 2.A contemporary way of teaching behavioral self- management and providing support for persons who are learning. 3.A compensatory strategy for persons who have difficulty problem-solving in high arousal conditions.

28. A Simple Personal Interventions Plan for ________ This plan is intended to assist you and those who may help you to learn more about yourself and get better at managing your emotions and behavior when the going gets tough. Consider it as a representation of ways you have responded in the past and a new start on ways you may use it in your future. 1.I am likely to have a bad day when… (List at least three situations that may precede a “bad day.”) 2.I am likely to get upset when… (List at least five events that produce upset for you.) 3.When I get upset, I notice a sequence that starts with __________ and may end with ___________. (Make a list from the first sign to other things that do or could occur.) 4.When I notice that a difficult situation is coming or when I begin to get upset, I will have the most success when I… (List the steps you need to take.) 5.Other people can help me by… (Identify who you need to help and list what you need them to do.)

32. Thank You Debra Braunling-McMorrow, Ph. D. Vice President Development NeuroRestorative (formerly MENTOR ABI) Debra.mcmorrow@thementornetwork.com

33. Suggested Readings: Getting Ready to Help: A Primer on Interacting in Human Service M. J. McMorrow, Brookes Publishing 2003 www.brookespublishing.com BRAIN INJURY PROFESSIONAL 2009 VOL 5(4) BEHAVIOR: RESPECTING INDIVIDUALITY AND PROMOTING ABILITY NORTH AMERICAN BRAIN INJURY SOCIETY BEHAVIORAL CHALLENGES AFTER BRAIN INJURY, 2007 BIAA www.biausa.orgwww.biausa.org LASH AND ASSOCIATES PULISHING AND TRAINING www.lapublishing.com