Family and friends of individuals with a traumatic brain injury (TBI) report behavioural changes such as aggression and disinhibition to be the most difficult consequences to cope with following injury. Psychologists working in rehabilitation are increasingly called upon to provide behaviour interventions that will minimise difficult behaviours in clients with a TBI. However, it is often people other than the clients themselves reporting the concerns. Problems with reduced self-awareness secondary to cognitive impairment contribute to this picture, but cannot be assumed to be the sole contributory factor. The psychologist must therefore decide when it is reasonably ethical to intervene in response to the concerns of others and how to provide effective interventions given this dilemma.
Behaviours including verbal aggression, physical aggression, reduced initiation of daily activities (adynamia), sexual disinhibition, social disinhibition, repetitive thoughts or actions (perseveration), absconding and wandering are often demonstrated by survivors of TBI. These behaviours frequently lead to difficulties in family reintegration and the experience of stress, anxiety and depression among family members (Verhaeghe, Defloor & Grypdonck, 2005).
Whilst behavioural changes can also be distressing for the client, the injury itself commonly results in a lack of awareness and concern about behavioural difficulties (Port, Willmott & Charlton, 2002). Disruption to frontal executive processes like self-monitoring and problem solving are thought to explain impairments in behavioural awareness. Interestingly poor self-awareness has also been shown to be an important risk factor for behavioural disturbance (Bach & David, 2006). It is therefore not surprising that concerns and appeals for help predominantly come from family and friends, as well are direct care workers, rather than clients themselves.
Psychologists working in rehabilitation roles are commonly asked to provide behaviour interventions for clients with TBI. Positive behaviour interventions are favoured, as these provide individuals with a better chance of succeeding in their social contexts (Ylvisaker, Turkstra & Coelho, 2005). This approach places less importance on the manipulation of consequences and extinction practices, and emphasises the use of natural and logical rewards for successful behaviour.
|COMMON POSITIVE BEHAVIOUR INTERVENTIONS|
Psychologists are therefore often faced with the ethical dilemma of whether to intervene in a client’s life without their explicit agreement. This raises important ethical considerations given that we know behaviour interventions are not risk free; they can be demoralising to clients with TBI even when limited to environmental change (Willer & Corrigan, 1993).
One guiding principal often found to be useful involves reflecting on whether behaviours are causing concern because of what the client did, such as the action of punching someone, or because of how others felt in response to their behaviour, such as the feeling of embarrassment or disgust when a client masturbates in public. Ethical decision making seems more clear-cut when behaviours are dangerous or at least when there are foreseeable risks to safety. When behaviours are difficult for others to cope with however, the concern is really about ‘where’ and ‘when’ the behaviour is occurring, which makes ethical decision making more complicated. A good rule of thumb in this instance is to provide interventions in only those contexts where not doing so would lead to a breakdown in relationships that are meaningful or supportive for the client (Sense Scotland Practice Development Department, 2003).
Decisions about ethical practice tend to not be so straightforward when concerns about dangerous behaviour relate to the client’s safety alone, such as in the case of a client going out alone despite their high risk of falls. This is because interventions in this situation are at risk of becoming paternalistic, for example restricting the client’s access to the community to minimise falls, and do not promote choice or freedom. The trade-off for safety may be despair and, in turn, deterioration in other behaviours such as aggression. Ethical dilemmas such as this are unlikely to be completely resolvable and a commitment to giving these issues due consideration on a client-by-client basis is most advisable (McGrath, 2007).
|CASE STUDIES EXPLORING ETHICAL DECISION MAKING|
June is a 61-year-old woman who sustained a severe TBI eight months ago and lives in a nursing home. Nursing staff report that June pinches and scratches them when they are assisting her with transfers. June does not remember this happening.
Kelvin is a 52-year-old man who lives in supported accommodation following a severe TBI ten years ago. Staff are concerned about him watching pornography on his computer as he does not turn it off when they come into his bedroom. Kelvin does not understand what all the bother is about.
Ray is 22 years old and has lived with his parents since sustaining a moderate TBI last year. Ray is visited by carers daily because he needs help with showering. Most of his carers have resigned due to Ray masturbating when they are assisting with showering. No-one has talked to Ray about this.
“Clients are not expected to accept they are wrong to think or behave as they do, but rather to consider that there may be more useful alternatives.” (Manchester & Wood, 2001, p. 163)
Engaging clients with a TBI in behaviour interventions is the ideal; however this can be difficult when the client denies having problems with behaviour (due to impaired self-awareness).
There are a number of different strategies or techniques that psychologists can try that may increase client participation; four of these are presented below.
The principal author can be contacted at Brooke.FROUD@austin.org.au
Bach, L.J. & David, A.S. (2006). Self-awareness after acquired and traumatic brain injury. Neuropsychological Rehabilitation, 16, 397-414.
Manchester, D. (2010). Motivational Interviewing: A workbook. UK: MLR consulting psychology.
Manchester D., & Woods, R.L. (2001). Applying cognitive therapy in neurobehavioural rehabilitation. In RL Wood & McMillan TM (Eds), Neurobehavioural disability and social handicap following traumatic brain injury (pp. 157-171). East Sussex, UK: Psychology Press.
McGrath, J.C. (2007). Ethical practice in brain injury rehabilitation. New York: Oxford University Press.
McPherson, K.M., Kayes, N., & Weatherall, M. (2009). A pilot study of self-regulation informed goal setting in people with traumatic brain injury. Clinical Rehabilitation, 23, 296-309.
Port, A., Willmott, C., & Charlton, J. (2002). Self-awareness following traumatic brain injury
and implications for rehabilitation. Brain Injury, 16(4), 277-289.
Sense Scotland Practice Development Department. (2003). Challenging Our Approaches to Behaviour: Module Two - Unit Three. Accessed 4 March 2012 from http://s387732493.websitehome.co.uk/documents/challengingBehaviour.pdf
Verhaeghe, S., Defloor, T. & Grypdonck, M.G. (2005) Stress and coping among families of patients with traumatic brain injury: a review of the literature. Journal of Clinical Nursing, 14, 1004-1012.
Willer, B., & Corrigan, J. (1994). Whatever it takes: a model for community-based services. Brain Injury, 8(7), 647-659.
Ylvisaker, M, & Feeney, T. (1998). Collaborative Brain Injury Intervention: Positive Everyday Routines. San Diego: Singular Publishing Group.
Ylvisaker, M., McPherson, K., Kayes, N., & Pellett, E. (2008). Metaphoric identity mapping: facilitating goal setting and engagement in rehabilitation after traumatic brain injury. Neuropsychological Rehabilitation, 18, 713-4.
Ylvisaker, M., Turkstra, L., & Coelho, C. (2005) Behavioral and social interventions for individuals with traumatic brain injury: a summary of the research with clinical implications. Seminars in Speech and Language, 26(4), 256-67.