Behavior change is difficult for any individual to accomplish. The process, however, can be infinitely more difficult for those who suffer from a traumatic brain injury (TBI) due to physical, cognitive, and emotional impairments associated with an injury. Successful reintegration into the community and return to activities of choice is often dependent on the individual’s ability to modify maladaptive behaviors that may result from the injury. Behavioral challenges that frequently require intervention following brain injury include aggression, disinhibition, difficulty relating to others, and a host of other behaviors.
A total reversal of behavioral problems after a brain injury may not be possible. A more realistic goal is to modify behaviors. There are several interventions available to assist with the modification of those behaviors that negatively effect goal achievement, successful community reintegration, or quality of life for individuals with TBI. The intent of this article is to describe and provide examples of current options for therapeutic intervention and examine their effectiveness for individuals with TBI.
There are a number of steps that can be taken proactively to set the stage in developing effective plans for behavior change.
Developing Trusting Relationships
It is important to build a trusting relationship with an individual who has had a brain injury. Much of what occurs during rehabilitation is based on trust that the individuals providing services understand what is important to the person receiving services. There must be trust that the recommendations providers make and activities they encourage, are designed to help the individual achieve his/her goals.
Trust is developed through honest, caring, and consistent interactions. It is important to be realistic with the individual. You cannot promise to ‘make him/her better.’ We, as family members or professionals, do not have all the answers to the individual’s problems. We may be most helpful by providing a comfortable, nonjudgmental atmosphere in which the individual can discuss his/her concerns and preferences, even if the concerns and the accompanying behaviors do not appear to be logical. The knowledge gained from such discussions is invaluable when developing behavior plans or carrying out treatment.
The importance of relationships in behavior change goes beyond relationships between professionals and a person with brain injury. Following a brain injury, an individual may feel isolated and depressed (Denmark & Gemeinhardt, 2002). Success in coping with or adapting to changes after injury, as well as in modifying maladaptive behaviors, is highly dependent upon the feedback and support an individual receives from his/her social network. A supportive network may include professionals, family, old friends, new friends, and persons who have had similar experiences.
Understanding the Behavior
Developing adaptive behavior first requires recognizing what may be contributing to the problematic behavior. Triggers, antecedents, and precipitating factors are terms describing that which precedes the behavior. Triggers to acting-out behavior may be internal or external (Caraulia & Steiger, 1997). Examples of internal causes of behavioral problems can be fatigue, hunger, lowered self-esteem, etc. External triggers may include a frustrating task, interaction with certain individuals, change in structure/ routine, increased level of stimulation, etc. In addition to understanding what may trigger maladaptive behavior, it is important to understand what occurs following the behavior that may serve to reinforce and hence maintain the behavior. For example, if a given behavior consistently results in a rewarding experience such as increased attention, the frequency of the behavior will most likely increase. Modification of antecedents and consequences to change behavior is discussed in more detail under the heading Behavior Therapy.
Recognizing and Responding to Precursors
Individuals often provide non-verbal and verbal signs prior to displaying the behavior of concern. A person’s change in behavior can represent a negative internal state. There may be signs of anxiety such as pacing and fidgeting. The face may become flushed; he/she may have difficulty maintaining eye contact or may display decreased attention to a task. An individual may also exhibit verbal signs, such as muttering to him/herself or increasing the volume of speech. Clearly, it is important to be aware of sudden, often subtle, changes in behavior (both non-verbal and verbal) in order to effectively intervene. Intervening early in the sequence of behavioral escalation is one of the most effective strategies for behavior change.
In order to select the most appropriate intervention for modifying behavior during rehabilitation, the following guidelines, outlined by White, Seckinger, Doyle, and Strauss (1997), need to be considered:
- Include the individual with TBI when developing a strategy. If a plan is developed without client input, it is not likely to be effective.
- Prioritize the functional needs of the individual. Consider his/her strengths and weaknesses.
- Analyze the tasks required for goal achievement. Individuals have more success if they can incorporate what they have already learned and know.
- Consider the learning style. Individuals can learn from written information, oral information, or a combination of both. Ensure the intervention is compatible with the learning style of the individual.
- Consider the individual’s willingness to participate in the therapy or strategy.
- Ensure that the strategy is practical. Time and funding constraints, family concerns, and environment limitations (i.e., in-patient vs. day-patient) should be considered.
Several different approaches have been used to modify behavioral problems in individuals with TBI, some with more success than others. Most of the therapeutic intervention strategies were developed originally for individuals with learning disabilities, emotional dyscontrol, and psychiatric disorders. Studies have shown that with some adjustments or combination of approaches, these intervention strategies can benefit individuals with TBI (Alderman, 2003). However, most researchers agree that additional studies should be conducted to better measure the effectiveness of therapeutic interventions that have been adapted for use with persons with TBI (Denmark & Gemeinhardt, 2002; Kinney, 2001; Manchester & Wood, 2001; Schlund & Pace, 1999).
From ResCare Premier. Used with permission. Third-party use prohibited. www.rescarepremiertexas.com.