Management of Behavioral Problems During Acute Rehabilitation of Individuals with TBI Tom Novack, PhD, University of Alabama at Birmingham Department of Physical Medicine and Rehabilitation and the Department of Psychology Page 5 of 5

Staff needs to recognize that they are not only rehabilitation specialists, but also teachers. It is essential for staff to model appropriate social behavior for patients. For instance, you should attempt to be a good listener and not interrupt others frequently. Taking turns in conversation is also important to show that everyone has an opportunity to speak. It is sometimes easy to overlook such basic rules when one is busy and must say something quickly.

You should select relatively easy topics for discussion when talking with individuals with TBI. Select something that will be easy for the person to comment about. For instance, family issues, sports, or the weather would be appropriate topics that are not too complex. Also, your responses should be as brief since longer comments are less likely to be understood by the individual with TBI.

Staff can model appropriate behaviors and it might be helpful to use role-playing. If the individual with TBI has engaged in socially inappropriate behavior it would be helpful to role-play a more appropriate response with them. For example, if a patient makes a sexual comment to a therapist, it would be beneficial for that therapist to discuss with the person more appropriate expressions of appreciation. The therapist could suggest saying “You have been very nice to me today” or “I like the way you’ve done your hair.” It is not helpful for staff to criticize the behavior without giving that person some idea of a better way to respond.

Denial of Disability

It is common that individuals with TBI do not fully recognize the deficits they exhibit. This can extend to cognitive problems, physical problems, or behavioral issues. Once again, the basis for this behavior is neurological, in part. There are areas of the brain that control a person’s ability to monitor themselves and the environment. There is also an emotional component in which, understandably, people are not willing to accept significant limitations in their life due to TBI.

Rehabilitation professionals are trained to help people cope with their disability. This means there must be some recognition of what disability exists for a particular patient. The staff may assume that individuals with head injury should be able to recognize their deficits and if they do not, it is the responsibility of staff to bring it to their attention. Unfortunately, this can result in some very negative confrontations in which a patient denies having a particular problem and the staff member disagrees very directly. When this occurs, the response of the injured person is often to become defensive and insist on the intactness of his/her abilities. This also undermines the personal relationship between the staff member and patient.

There are some instances in which you must confront denial of disability. If the patient is in danger due to the denial, there must be some intervention. For example, an injured individual who is non-weight bearing thinks he/she can ambulate and tries to do so. They must be confronted directly, but in a sensitive manner. When this does occur, you need to emphasize that the situation may change, such as the person may be able to ambulate in the future. They can indicate why the person is unable to perform the particular task, stating that the person’s balance is significantly impaired.

What about when the denial does not result in a significant danger to the person? In this situation, one way to deal with the denial is to simply ignore it. Change the topic and move on to another activity. In most cases, the awareness of deficits will increase with time as a person participates in therapies. This experience will have more impact than simply telling people about their problems. An equally acceptable approach is to gently address the inaccurate perception on the part of the individual with the head injury once, but then to avoid arguing over the statement. If an individual with a head injury disagrees with you concerning their capability of performing a particular action, there is usually not much benefit to be gained from arguing with them about it. In most cases, the lack of awareness itself is a sign that reasoning skills are inadequate. It is important that you take care not to embarrass the person in front of others by commenting on deficits in a teasing or demeaning manner.

A little bit of humility may also be helpful in dealing with patients who claim abilities that staff doubt. Rehabilitation professionals do not have access to “the truth” anymore than other people. Your ability to judge the capabilities of our patients is based on our experience with rehabilitation. There will always be instances in which someone can perform an action that you do not think they could do. This is actually a very positive development. If a person insists they can do something, in some instances it might be appropriate to allow them to attempt the action under supervision. A good example is a person who believes that they can engage in kitchen activities even though therapists may doubt that capability. Eventually, it may be necessary to have the person participate in cooking activities under the supervision of an occupational therapist to prove their capabilities.

Final Words

The most important thing to remember in working with individuals with TBI is to remain calm and be flexible. Do not take it personally when patients exhibit behavioral problems. As teachers we need to model calm and sensitive behavior if we are to help patients and their families as they struggle through a difficult time.

This paper is published by the UAB Traumatic Brain Injury Model System, supported by grant #H133A980010 from the National Institute of Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, Dept of Education, Washington, DC. Opinions expressed are not necessarily those of the granting agency.

From the University of Alabama at Birmingham Traumatic Brain Injury Model System. Reprinted with permission. http://main.uab.edu/tbi/show.asp?durki=9505.

 Comments

There are currently no comments for this article