Ain't Misbehaving

Harvey Jacobs, PhD, Brain Injury Professional magazine
Ain't Misbehaving

Behavior is generally recognized as the most common yet most misunderstood aspect of the human condition. To some people behavior is inferred when somebody is acting out, or responding in a manner that is not acceptable to others. Is it possible to mis-behave if there is nobody else around to observe or experience its effects? And just what constitutes mis-behavior? Some people will identify absolute moral codes to behavior while others note the relative nature of its effects. Is it always wrong to kill? Is it always right to indicate acceptance and affection of another? Just what the heck does “appropriate” mean anyways?

To others, the concept of behavior constitutes super-human feats or note-worthy abilities. We honor those who behaved unexpectedly or who placed themselves in harm’s way while doing the right thing for others. Sports heroes are honored for breaking old records. Writers, singers, artists and others gain acclaim for breaking new venues and new barriers.

But what about the average guy? You know, the one who gets up every morning, does what he is supposed to do, goes about his business without “inappropriately” bothering others. Does this constitute behavior? Of course it does. In fact everything we do constitutes behavior. Taken from no less of an authorative source than the American Heritage Dictionary, behavior constitutes: The actions or reactions of a person [or animal] in response to external or internal stimuli.1

For too many years the field of brain injury rehabilitation maintained dubious disciplinary distinctions regarding cognition and behavior. There have been vociferous debates and arguments regarding cognitive vs. behavioral approaches; as if a forced dichotomy existed. Effective behavioral change strategies were seen as temporary or “not real treatment” by some people because the behavior of focus would change when the strategy or developed supports in one’s life stopped. Cognitive strategies were disdained by functional empiricists because of their conceptual rather than functional nature and difficulties generalizing across environments. Things that did not fit into an ABC template were suspect. Some viewed learning as the province of cognitive strategies whereas stopping “bad behavior” as the domain of behavioral approaches. In lighter moments there were the jokes that “Behaviorists can’t think” and “Cognitivists think they can!” In the process, people were missing the forest for the trees and often arguing about the same difference!

Conceptualizing Behavior

Behavior constitutes the individuality and the sum of our actions, especially as they are represented to others. It is the dynamic product of the complex interactions from within and around us, and much like life it is constantly changing. How do I infer that you are “thinking?” Most likely because you answer a question, produce a paper on a topic, choose one of several offered choices, etc. I don’t actually see you think, but I see (or can infer) the product of your thinking by your behavior. Observing and documenting behavior is an ongoing process because our behavior is always changing. What you were doing just before you began reading this article is different than what you are doing now and will be different from what you will be doing several minutes, even several seconds from now.

So what causes behavior? Many things – probably more than you can or may want to consider. We can start with environmental factors such as the antecedents (cues) that precede behavior, the consequences that follow behavior, the overall environmental circumstances in which the behavior is occurring; and the contingencies between these three elements. Is it noisy or quiet, familiar or unfamiliar, supportive or hostile, static or changing, crowded or abandoned; and what about all the shades of gray in between?

Neurological impairments and their corresponding cognitive and perceptual disabilities clearly host a wide range of salient factors that effect behavior. We are all aware of the challenges that changes in attention, concentration, awareness, memory, initiation, organization, abstraction, sequencing, stamina, vision, smell, taste, touch, and a multitude of other factors unique to the individual can proffer on behavior. Now add to this the interactive and integrative effects that these multiple factors can have on any instance of behavior, let alone across the continuing cadence of life. Remember, it is not how you experience the world through your “apparatus” that is important, but how the person of focus experiences the world through theirs.

Effects of physical impairments including mobility, paresis, paralysis, damage to other body parts, pain and physical fatigue all play their roles, as do pre-morbid conditions. Throw the effects of medications into the mix. Is it any wonder that each person and brain injury is unique?

Changes in daily routines, especially changes in ability or inability to work, go to school, or get around the community can have profound effects. What happens when a job that defined your life’s focus for so many years is lost; when going to the store for a gallon of milk now takes all day since you can’t drive and have to rely on public transportation – let alone the fact that you will probably forget why you were going to the store by the time you get there; or when good friends fade and no longer answer the phone?

It doesn’t take a rocket scientist to understand how one’s behavior will change under such conditions regardless of neurological impairment. People who lose jobs, retire when they are not ready to, lose loved ones, experience major environmental disasters, or a whole host of other calamities will also demonstrate significant behavior change in the absence of a brain injury because their lives and worlds have changed. This does not minimize the tremendous effects of a brain injury on behavior, but rather underscores the other collateral issues that are involved.

In every case, regardless of the person and circumstances, their behavior changed when circumstances and events within and around them changed. Clearly, they “ain’t misbehaving” but “simply” behaving differently, and in most situations BEHAVING reasonably to different circumstances. In fact, at the time such “inappropriate” behaviors may be very adaptive for the person engaging in them. You would probably do the same in the same situation and under the same circumstances.

Choice and Responsibility

This brings up several issues, the first of which is the timeless free will vs. determinism – personal responsibility debate. This debate generally argues between free will, noting that people make unexpected choices in light of overwhelming odds, so behavior cannot be determined and by making choices people are responsible; vs. the concept that much of our behavior is determined by the many prevailing variables that effect it, even if we don’t understand them all. This side of the argument often notes that while we clearly cannot always accurately predict the weather, few of us would ignore the environmental and climatological factors that produce it. Subsequently, if any part of our behavior is determined, can we be responsible for such behavior since it was the product of a wide range of variables, many of which were beyond our control and hence not of our choice or responsibility?

Sorry, I don’t have an easy answer on the free will vs. determinism debate, though I lean towards determinism as part of the overall equation. What we don’t know about ourselves as a species and how we fit into the “big picture” far exceeds what we do know – sort of an existential agnosia.

The concept of personal responsibility may also be more accurately framed in terms of situational accountability. This account focuses on the “rules for the road” that a person may be expected to follow in a given situation as well as their ability to do so. For example, nobody cares if I sing in the shower because they can’t hear me. On the other hand, if I sing in the library I could get in trouble given their basic rules of being quiet and respecting the ability of others to concentrate. If you want to drive you better be able to handle all of the variables involved on the road, or stay off; and if you don’t stay off you may get pulled off by your friendly state trooper (for the benefit of the rest of us). Play golf at putt putt? No problem. Play golf on the PGA circuit? Only if you’re a big dog.

Clearly situational accountability varies with the task, community, culture, heritage, orientation, etc. and the aforementioned examples are relatively simplistic compared to actual daily life challenges. However, situational accountability establishes the skills and abilities a person is expected to bring to the table, the supports or assistance they may expect in the situation and the criteria for evaluating performance and continued membership in a given setting. When someone is “not appropriate,” we are saying that they are not following the expected rules or properly using available resources within the setting. Problems can clearly arise when a person’s judgment of their abilities and expected rules differ from that of other members of the immediate community.

Facilitation

If you accept the relationship between changes in behavior as a function of changes in variables that effect behavior, it then follows that “adverse” behavioral change is a warning sign that something is out of balance. A person is not “misbehaving” but “reasonably” behaving to a different set of salient factors.

Theoretically, by addressing the aberrant factor(s), the behavior of interest will also change. Practically, however, it is not always so easy. The contributing factors may not be readily identifiable, accessible or amendable for change. For example, we still can do woefully little to repair actual neurological impairment. A person with poor self-awareness may insist that they are capable of driving when others disagree, not understand why comments they made in a social setting upset someone else, or not even realize that they made a disparaging comment. Pre-morbid issues that were not successfully addressed prior to the brain injury may remain prominent. There is likely to be disagreement and possible conflict among parties in such situations. Still, this approach will be effective more often than not, especially with newly developing challenges. It also helps to understand that the person in question is usually doing the best they can in such situations within the information and abilities that they possess.

At issue, however, is the concept of not fixing something unless it is broken. This is simply too costly and detrimental when considering behavioral challenges following brain injury. By the time behavioral challenges garner professional attention they are usually at a crisis level where the urgency of the immediate situation typically obscures the initial point of focus. As a result, we too often equate behavioral intervention with stopping or preventing dangerous or highly irritating behavior rather than facilitating personal competency that would have likely avoided the problem in the first place.

It is just as easy, if not easier to identify proactive skills and abilities that facilitate individual success and the factors that support such behaviors. Obviously if we can operationally define challenging behaviors and identify the salient factors that facilitate such behavior, we can also operationally define proactive behaviors and identify the salient factors that promote functional competence.

This type of approach offers multiple benefits to the person of focus as well as others in their world. Nothing breeds success like success and people who have plans, tools and supports to negotiate life’s daily challenges are less likely to “melt down” or disrupt the lives of others. There is greater likelihood for success, even in difficult situations, when relationships are built on support and respect rather than confrontation. Building honest and positive relationships is often cited the single most important approach to curbing “problem” behaviors. It is also easier and more economical to do things with the wind at your back than to fight on oncoming gale.

Consider the “typical” behavior plan that extensively identifies the aberrant behavior and the steps suggested to stop the problem behavior. Somewhere near the bottom of that plan there will be a brief statement to the effect of: “and socially reinforce the person when they act appropriately.” Unfortunately, little thought is given to what is socially reinforcing to the person or exactly what “appropriate” constitutes. When the plan’s focus is on stopping rather than supporting, we fail to articulate the structure and supports required for success. As a result many people quickly relapse into problem situations. Staff is just as vulnerable, especially when the focus of their training is on the “can’ts” and “shouldn’ts” rather than the possible. They become enforcement officials rather than coaches and mentors.

Now consider a behavior support plan that identifies a goal that the individual of focus and others have agreed to work on and the steps required for success. It articulately identifies what the person is independently capable of and where they need support. Perhaps the person has difficulties with initiation which can be overcome with a cue from another person, or visual perceptual challenges that require that tools be set up in a specific configuration to be properly recognized, etc. When problems develop, this approach seeks to first work out the problem towards the proactive goal, rather than blame the behavior or the individual. It also emphasizes the multiple salient factors that contribute to behavior and the means to use such factors to personal advantage.

In summary, the concept of “behavior” is not just relegated to “bad things” that people do, but represents the sum of everything that we do. People don’t “misbehave;” they behave in relation to a diversity of internal and external factors. In most cases of behavioral disruption, recognizing that the problem (salient factors out of balance) and not the behavior is the problem will help to stabilize challenges, once such factors are addressed. However, this alone does not constitute sufficient behavioral programming or support. Rather, we must also recognize the proactive goals and abilities of each individual and work to optimize these same salient factors for each person’s overall success and quality of life. Ultimately, a variety of approaches and orientations may be required for any person or situation, but focus on ability and success first. An ounce of prevention is always worth more than a pound of cure, especially when served with heaping portions of personal respect.

About the Author

Harvey Jacobs earned his doctorate in psychology and behavior analysis from Florida State University, was a Post-Doctoral Fellow at the Johns Hopkins University School of Medicine, and an NIHR (NIDRR) Mary Switzer Research Fellow. He has served on faculty at the Johns Hopkins University School of Medicine, UCLA School of Medicine, and Temple University; as well as in staff, administrative, and consultant roles with numerous academic, medical, rehabilitation, community, assistive living and nursing home programs. Now in private practice, he is also a partner in Lash and Associates Publishing/Training and serves on a number of professional boards. His current interests include behavioral rehabilitation for neurological, psychiatric, medical and developmental disorders; brain injury; evaluating and treating “treatment refractory” cases; outcomes research; vocational rehabilitation; family systems; staff training; and community integration. His work in organizational and systems management focuses on developing and operating comprehensive programs in both clinical and business settings. Dr. Jacobs has received millions of dollars in grants from federal, state and private foundations for his work and is the author of numerous books and articles. His new book, due in 2009 is titled: DON’T “DON’T”: Understanding Almost Everybody’s Behavior After Brain Injury.

References

The American Heritage® Dictionary of the English Language, Fourth Edition, Houghton Mifflin Company, Boston, Massachusetts, 2006.
 

Posted on BrainLine March 31, 2009.

From Brain Injury Professional, the official publication of the North American Brain Injury Society, Vol. 5, Issue 4. Copyright 2009. Reprinted with permission of NABIS and HDI Publishers. For more information or to subscribe, visit: www.nabis.org.

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Comments (2)

My son is 19


There can still be benefits to distinguishing between cognitive and behavioral therapy.

Years ago, as a music teacher, I discovered it is nearly impossible to teach perfect pitch to children using a cognitive approach, and it is nearly as impossible to teach it to individual children with a behavioral approach, but it is relatively easy to teach perfect pitch to a group of children, by associating a set of tones with a daily routine, and then asking them to repeat what they heard. (I don't think age has anything to do with this, but my experience was teaching children). After about two weeks of daily experience hearing a set of tones without being asked to think about them. The group can repeat those tones without hearing them. (a couple of classes each year took up to six weeks, but eventually all of my classes were able, as a group, to sing specific pitches without a reference sound)

Similarly, group exercises with intervals can be used to teach relative pitch. Once the group can reproduce these pitches and intervals, all taught by association rather than any specific instructions, individuals can also be given the same prompts and produce the same responses. These skills are similar to muscle memory in that no cognitive process is involved, and "just like riding a bike," these skills return easily given the same prompts.

Once children have been behaviorally trained to produce specific pitches and intervals without thinking, they can be taught cognitively to associate those pitches and intervals with sheet music, and within a short time, it is relatively easy to give them (as a group) unfamiliar sheet music and for them to sing the tones without having heard it first (other than the tendency for them to "hear" the tones in their heads before they ever sang).

A group of children who have been behaviorally trained to know pitches and intervals and then cognitively trained to associate pitches and intervals with written music symbols can quickly display a level of musical understanding that many adults never successfully learn using a cognitive-only approach.

On the other hand, without cognitive training, it would be nearly impossible to take the next step from muscle-memory grasp of pitches and intervals to sight-singing music.