NeuroRehabilitation An Interdisciplinary Joul'llll
ELSEVIER
NeuroRehabilitation 9 (1997) 205-212
Compensatory strategies for people with traumatic brain injury Susan Martin White, Suzie Seckinger, Margaret Doyle, David L. Strauss* ReMed, 625 Ridge Pike, Building C, Conshohocken, PA 19428, USA
Abstract This article will describe the development and use of compensatory strategies for people with traumatic brain injury. Brain injury results in a wide variety of physical, cognitive, communication and behavioural deficits which impact on daily living skills, work and recreation. Because of these problems, strategy development may be required to address many aspects of a client's life. As this article shows, the compensatory strategies incorporated into one community-based, real-Life rehabilitation programme in Philadelphia, Pennsylvania, are as varied as the challenges they seek to address. © 1997 Elsevier Science Ireland Ltd. Keywords: Traumatic brain injury; Compensatory strategies
1. Introduction
A yellow post-it note on the back door reminds the busy executive not to forget his notes for tomorrow's important presentation. A stack of books strategically placed in the middle of the bedroom helps a busy teenager remember her homework for school. Both the yellow note and the stack of books are simple, useful strategies,
* Corresponding author.
designed to help these individuals accomplish a task which is difficult for each of them. For the person with a traumatic brain injury (TBI), the use of compensatory strategies serves the same purpose: to enable the individual to reach a higher consistency of success in performing a task and a higher level of independence than he or she would accomplish without the strategy [1]. Compensatory strategies for the person with TBI are used to overcome barriers and challenges in a wide range of areas - including attention and concentration, memory, behaviour,
1053-8135/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 1053-8135(97)00031-0
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motor skills and daily living skills. The goal of compensatory strategies is to focus on how these deficits effect the individual and to learn to use the strategies to compensate in real life situations involving work, leisure and social settings. However, unlike the absent-minded executive or the busy teenager, individuals with TBI may not understand that they need strategies, or recognize which situations call for strategy development. Their neurological injuries may have caused diminished awareness in each level of the so-called 'Awareness Pyramid': Intellectual Awareness, the ability to understand that there is a difficulty in the way the person functions; Emergent Awareness, the ability to recognize the problem as it occurs; and Anticipatory Awareness, the ability to anticipate that a problem will occur, as a result of the individual's impairment [2]. In some cases, individuals with TBI may have been injured before their strategy systems were developed or have no memory of specific strategy systems to rely on. Still others will discover that after their brain injuries, the strategies they once used no longer work. This helps explain why the development of compensatory strategies is critical for individuals with TBI. The use of compensatory strategies in rehabilitation 'is based upon the theory of functional adaptation. Functional adaptation assumes that clients need to develop alternative ways to manage deficits [3]. The use of compensatory strategies is extremely important in the rehabilitation of persons with traumatic brain injury. They are taught in therapy sessions and in the community using actual situations of real life as the prototype for strategy development. In one community based, comprehensive rehabilitation programme for individuals with TBI - located just outside Philadelphia - compensatory strategies, restorative treatment and alternative skills are developed for clients in an effort to increase their ability to be independent and live in the community. Persons with brain injury are appropriate for admission to a community based programme when they are medically stable and at a Rancho level of five or above [4]. Because persons with TBI often do not generalize skills well [5], community based rehabilitation is
the best way to ensure that clients implement strategies into their daily lives. Strategy development is based on a strategy hierarchy that accounts for each individual's ability to function independently vs. their need for assistance. And though each client with TBI must deal with certain barriers, the use of strategies seeks to capitalize on each client's particular strengths and works to build new skills in those areas. As this rehabilitation centre near Philadelphia is dedicated to real-life rehabilitation, strategies and alternative skills are developed for every phase of a person's life - from room organization and paying bills to coping in social situations and safely crossing the street on the way to work. 2. Strategy development Depending on the strengths and needs of the client, a strategy can be utilized in many areas of rehabilitation: in restorative treatment, which attempts to help a person reacquire or improve lost skills; or in compensatory skill development, which works around deficits to teach alternative ways to accomplish a specific behaviour. Strategy use is not appropriate for those who are medically unstable or who are undergoing rapid neurological change. Compensatory strategies utilize a person's more intact skills and strengths, breaking a task down step-by-step and utilizing external and internal cues to successfully complete a task [6]. A strategy is defined as the deliberate and consistent use of a carefully designed procedure to reach a goal or accomplish a task which is difficult [1]. Hundreds of strategies have been developed to help individuals with TBI remember to take their medication, cook dinner, catch the bus, mail a letter and water the flowers. No two strategies are alike; rather, each strategy is client-specific, taking into account not only the client's cognitive and physical abilities but his or her personality as well (see Sidebar 1). Consider, for example, the strategy developed for a client named Mark who was frustrated by transfers during his physical therapy sessions. The staff developed a strategy to verbally review three different rationales with Mark before doing the
S.M. White et at. / NeuroRehabilitation 9 (J997) 205-212
transfers. At the conclusion of the strategy was listed the message: 'Do not use the word 'safety'
Strategy sidebar 1 Strategies have been developed in 12 different categories to assist clients with traumatic brain injuries. These categories include: Categories
Available strategies
Communication
Speech intelligibility/pragmatics oral/written comprehension conversation skills following oral/written directions
Self-awareness
Orientation to person, place, time orientation to brain injury barriers comprehension of how brain injury barriers affect daily living situations
Problem solving
Problem solving/decision making in home / community /workplace
Behavior
Management of undesirable behaviors social skills
Substance abuse
Drug and alcohol education Maintenance of sober lifestyle Refusal skills
Time management
Following schedule Planning schedule
Money management
Budgeting Shopping Banking Paying bills
Mobility
Primary mobility skills Pedestrian safety Topographical orientation Use of public transportation
Medical
Self-medication skills Prescription refills Medical appointments
Hygiene/grooming
Personal hygiene Dressing Laundry
Meal preparation
Kitchen safety Meal preparation Menu planning Shopping
Room /house / apt. upkeep
Cleaning Room/apartment organization
207
Strategy sidebar 1 (Continued) Recreation
Leisure options in home and community Participation in leisure activities Recreation planning Socialization
Vocational
Interviewing skills Job training Social skills in the work place
with Mark. He considers it uncool to be concerned about safety'. To help develop each unique strategy, the staff developed these guidelines: •
Recognize that the client 'makes' all the strategies. From the beginning, bring the client into the process of developing a strategy, which helps the client 'own' the idea and be interested in making it work. If the strategy is developed in isolation without client input, it probably won't work. • Prioritize the functional needs of the client. Consider the client's strengths (good attention skills, for example) and barriers (can't retain information). Recognize the total picture of the client's life, including the client's desires, the family's needs and the environmental concerns. Do not overwhelm the client or the family with too many strategies at once. • Analyze the task. Do not just hand the client a checklist and expect results; observe the client's natural approach to the task. People learn and remember better if they are allowed to incorporate what they already know or can do. • Consider the client's learning style. Some clients learn better with written information, some are oral learners and some do best with a combination of both. Incorporate demonstration and pictures into strategies for those who are visual learners. Some clients may have the ability to work with presets (a verbal review with the client before
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he/she starts a task, one that reviews directions or behavioural expectations or both). Help the client develop written or verbal cues that might include such compensatory strategy tools as check lists, key words or recorded messages. Prosthetic memory devices help resolve memory problems with external devices like coloured key jackets, car beepers and whistle activated devices, wrist watches that store phone numbers and names, appointment calendars and electronic pillboxes, to name a few [7]. Such devices do not work for all clients, but are worth considering. •
•
Practice different approaches. Take into account the client's personality, the brain injury barriers, interests and willingness to buy into the strategy implementation. Determine if the strategy is practical. If each strategy takes 3 h and requires one-on-one supervision, chances are it won't be successful for very long. Consider the setting, availability of staffing and help, family concerns and client limitations when developing a strategy.
in implementing strategies. 'Look how far you've come,' is a good way to review past accomplishments, along with praise, rewards and recognition (see Sidebar 2). Implementing any strategy must take into account a client's ability to function independently vs. their need for assistance. In the strategy development hierarchy, the following levels exist: •
•
3. Strategy implementation A client with TBI mayor may not understand why a strategy is necessary, but he or she can typically comprehend what the strategy can help him accomplish and in trying to implement a strategy, connecting the strategy to an intrinsic or extrinsic goal will help a client embrace and use a strategy he may not understand. Strategies, for instance, can be linked to life goals or discharge placement plans. Strategies that help a client travel to a community centre may enable the client to meet new friends, which is often a major goal of clients with TBI who experience social isolation. A work-related strategy may help a client get a job and strategies that help clients adopt independent living skills such as getting dressed, cooking and balancing a checkbook may help these clients realize their goal of living on their own. Ask the client directly, 'What do you want most?' and then review how different strategies can help him meet these goals. Motivating the client to be proud of his progress is a key factor
Staff based, environmental. In this level, clients do nothing voluntarily to carry out a strategy. They rely on maximum assistance from staff for constant supervision and cueing. It is the staffs tone of voice, cueing systems and environment (quiet room with limited distractions, for example) that make the strategy successful. Because the client is not aware that strategies are effective, he relies totally on the staff to help him respond to the environment with appropriate, learned strategies. Staff and client based. At this level, both staff and client have a role in making the use of strategies successful. The client begins to understand that they actually need to use strategies to reach a goal. This awareness is key to
Strategy sidebar 2 When using compensatory strategies with clients, it is helpful to remember the following: Do:
Use cueing hierarchy (maximum-minimumindependent use). Ask questions to clarify strategy rationale or steps. Provide rationale to client. Remain positive and patient. Recognize that some trial and error may need to occur. Be aware of your own non-verbal communication and its impact on the client. Communicate failure/success of strategy to other staff. Review /revise strategy frequently to increase effectiveness.
Don't:
assume strategy will always work. Expect success quickly. Sabotage by improvising your own strategy instructions. Be afraid to refer to written strategy with client. Get into a power struggle with client. Take conflicts personally.
S.M. White et al. / NeuroRehabilitation 9 (J997) 205-212
•
their use of strategies in a more independent manner. In this level, the staff will preset a client to use a checklist for shopping. The client will be given cues to use the list. However, it is the client's role to make sure he uses the list when shopping. Moderate cueing - checking back in with a client on an intermittent basis - is critical at this level. Client based. When the client reaches this level, he is able to initiate and monitor his own strategies. The client may need help to problem-solve or to recognize when a strategy no longer works, but he initiates the use of strategies at appropriate times. This level of self-awareness allows the client to live a more independent lifestyle.
4. Role of awareness in strategy development Level of awareness and severity of deficits both play major roles in determining the level of support necessary for successful implementation of a strategy. It is the client's awareness of deficits and the client's ability to understand how these deficits affect daily life that is the critical element in determining how independently a person can use or generalize a particular strategy [2]. Use of a rationale is often critical to a client's acceptance of a strategy. For persons with diminished awareness, rationales provide an explanation of which brain injury barriers are preventing successful completion of a task or interaction and how the use of a particular strategy can promote success. An example of this is a rationale of a time management strategy written for Ben: 'Ben, you do a great job getting showered, dressed and breakfast completed each morning, but you get easily distracted by other things in your apartment and this often makes you late. Use of a timer and a checklist help to keep you on track so you can get to work on time and can be successful at your new job'.
Dependent upon the person's needs, a rationale may be reviewed with the client as a preset immediately prior to strategy use, reviewed on a daily or weekly basis with family or staff, or be reviewed independently by the client on his own. Rationales are also useful for staff or family
209
members. They remind the caregiver what the purpose of the strategy is and why the strategy is important for client success. 5. Examples The following strategies have been developed for different clients with traumatic brain injuries. Each strategy includes a goal that is important for each client. 5.1. Strategy 1: topographical orientation in community 5.1.1. Treatment / discharge focus: mobility 5.1.1.1. Rationale. James has difficulty organizing verbal directions when traveling to unfamiliar destinations in the community. These recommendations will assist James in traveling in the community. 5.1.1.2. When / how strategy should be used. James should work with staff for each new destination and continue to be supervised by staff until he demonstrates independence in initiating and carrying through with the strategy without any staff intervention. James should review this strategy prior to gathering any information or directions to a new destination. 5.1.1.3. Recommendations for James.
1. Copy down phone numbers and address for destination. You will need this if you get lost. 2. Gather as much information as possible not only for what streets and directions to tum but also distances between turns and landmarks prior to a tum. For example: • After Bala Shopping Center, look for Montgomery Avenue. • At Montgomery Avenue, tum right. 3. Write down directions in step-by-step format. Do not use a paragraph form. 4. Keep directions concise and to the point. For example: • At the second light, tum left. • Go approximately about 3 miles and look for the Sunoco. • First light after the Sunoco (Fairview Avenue), tum left.
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5. Prior to starting back from your destination, rewrite the directions for returning. 6. Keep your directions in your Direction Notebook. 5.1.1.4. Recommendations for staff. Check directions for accuracy and use of correct format. 2. Accompany James on the route the first time. If he does not require any staff assistance, then he will be cleared to travel that particular route. Staff should continue to accompany him on a route until he has demonstrated independence. 1.
5.2. Strategy 2: cooking dinner 5.2.1. Treatment/discharge focus: cooking safety 5.2.1.1. Rationale. Amy does not always follow recipes accurately, follow general safety principles or remember to set the timer. Amy has agreed to use a timer and review lists in order for her to learn to cook safely and more independently. 5.2.1.2. When / how strategy should be used. For Monday, Thursday and Friday dinners. Amy uses the microwave independently on Tuesday, Wednesday and Saturday. 5.2.1.3. Time needed to use / complete strategy. Sixty minutes. 5.2.1.4. Amount of assistance needed. Maximum cueing to review safety lists. Minimum assistance during cooking process. 5.2.1.5. Procedure.
1.
Staff should cue Amy to review safety tips and cooking and baking steps posted on the side of the refrigerator before cooking in order to cook more independently and safely. Some sample lists include: Safety tips • Use scissors to open packets, not knives. • Cook one thing at a time. • Tum pot handles in when on stove top. Cooking and baking tips • Read through recipe directions completely.
• •
Gather all ingredients. Preheat oven (remove plastic and paper from stove top). 2. Staff should tell Amy that they will be filling out a cooking checklist after cooking with her and that the checklist will be reviewed after 2 weeks. If Amy does well, she will be able to cook more independently. The cooking checklist includes the following items: • Amy reviewed safety and cooking steps prior to cooking with staff. • Amy accurately followed recipe measurements without help. • Amy accurately followed recipe directions without help. • Amy removed all flammable objects from the stove top without staff cues. 3. Once lists are reviewed, staff should avoid helping or cueing Amy unless she is not safe or asks for help. Before jumping in to help, see if she can correct mistakes herself or figure out what to do. 4. Staff should fill out cooking checklist in the back of the menu planner binder after meal preparation. 5.3. Strategy 3: dressing packets
5.3.1. Treatment/discharge focus: hygiene / grooming 5.3.1.1. Rationale. Due to organization and memory barriers, Paul has difficulty organizing his clothes each morning. This strategy is designed to help Paul keep together all the clothes that he needs for the next day so that he can dress independently. 5.3.1.2. When / how strategy should be used. On laundry day. 5.3.1.3. Time needed to use / complete strategy. Ninety minutes for Paul, 30 min for staff. 5.3.1.4. Amount of assistance needed. Minimal. 5.3.1.5. Procedure On laundry day, Paul should fold all clean clothes and leave them on the bed. 2. Staff should arrange clothes into piles: pants, shirts, socks and underwear. 3. Paul should take one piece of clothing from 1.
S.M. White et af. / NeuroRehabilitation 9 (1997) 205-212
each pile and pack them into a clothing bag until seven bags are completed. 4. Staff should check for colour coordination and to make sure all packets are completed. 5. Paul should put completed clothing packets in the dresser (top two drawers). 6. Each night during the evening routine, staff will check with Paul to make sure there is a clothing packet available for the next day. Note: any extra clothing should be kept in the bottom drawer for variety. Staff can pull out clothing from this drawer to exchange with the ones Paul has been wearing for a while. 5.4. Strategy 4: communicating with adult family members
5.4.1. Treatment/discharge focus: social skills 5.4.1.2. Rationale. In communication, taking turns during conversations is required to avoid conflict and to allow for positive/nurturing results. Communicating in this manner helps John avoid 'shut down' or 'outburst' reactions to tense situations. John has developed this strategy with his speech therapist and has agreed to follow it for the next 2 weeks to see how it works. 5.4.1.3. When/how strategy should be used. When conversations are becoming tense. 5.4.1.4. Procedures. The following steps will be followed when an interaction is becoming tense for John or another family member: John or a family member will state 'Please be quiet and listen', or 'I'm becoming upset, do you mind if we continue this later?' or 'I'm feeling tense, what about you? Can we start over?' 2. If the conversation continues, John and the family member will agree to take turns. 3. Each will speak, and the other will listen. 4. Both should move to a quiet place to decrease distractions or simply sit to continue the discussion. 5. A compromise or a simple 'agreement-to-disagree' are positive ways to end the conversation. Both may also agree to try to work it out later. 1.
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6. Conclusion Strategies make everyone more successful and the success of every strategy depends on many factors, including the awareness level of each client and the amount of practise and repetition allowed for each strategy. One key element necessary for successful implementation is staff monitoring, with constant evaluation of the strategy and on-going assessment once it becomes successful. When evaluating a strategy, staff need to remember that most strategies are not immediatly successful. Develop goals to help determine how long it should take for the client to use the strategy successfully with different levels of assistance. Remember that trial and error is expected in mastering the strategy and that good communication between the developer of the strategy and the user of the strategy is essential. Sometimes, strategies fall apart, and it is up to the staff to evaluate what went wrong and develop a new strategy for the client. It is important to remember that clients do not always make progress. It is acceptable for clients to stay at one level within a strategy progression, particularly if there are other changes in the client's life. Staff assessment may sometimes determine that more assistance is necessary to make the strategy successful or to help the client reach a higher consistency of success in performing a task before proceeding to a higher level of independence. Once a strategy is considered successful, an on-going assessment is critical. Questions to consider include: is the strategy still working? Can the client progress to a more independent level? Should the strategy be modified to meet the changing needs of the client's environment or a change in lifestyle, moods and medical status? In our experience, strategies are most successful when they are developed in a setting similar to the one where it will be used - be it at home, at work or in the community. In these settings, the person with TBI can develop awareness of barriers and see how the use of strategies can positively impact daily life in real life situations.
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References [1] Strauss D. Compensatory Strategies. Orientation Booklet. ReMed,1995. [2] Crosson B, Barco P, Velozo C, Bolesta M, Cooper P, Werts D, Brobeck T. Awareness and compensation in postacute head injury rehabilitation. J Head Trauma Re· habil 1989;4(3):46-54. [3] Harrell M, Parente F, Bellingrath E, Lisicia K. 'Cognitive rehabilitation of memory - a practical guide'. Aspen Publishers, 1992:185-218. [4] Rancho Los Amigos Scale of Cognitive Levels and Ex· pected Behavior. Los Amigos Research and Education Institute (L.A.R.R.I.), Downey, CA.
[5] Gobble, EMR, Ylvasaker M. 'Community reentry for head injured adults'. Little Brown and Company, 1987:107. [6] Milton SB. Compensatory memory strategy training: a practical approach for managing persisting memory prob· lems. Cogn Rehabil Nov/Dec 1985:8-15. [7] Parente F, Anderson·Parente J. 'Retraining memory techniques and applications'. CSY Publishing, 1991: 175-191.
ELSEVIER
NeuroRehabilitation 9 (1997) 205-212
Compensatory strategies for people with traumatic brain injury Susan Martin White, Suzie Seckinger, Margaret Doyle, David L. Strauss* ReMed, 625 Ridge Pike, Building C, Conshohocken, PA 19428, USA
Abstract This article will describe the development and use of compensatory strategies for people with traumatic brain injury. Brain injury results in a wide variety of physical, cognitive, communication and behavioural deficits which impact on daily living skills, work and recreation. Because of these problems, strategy development may be required to address many aspects of a client's life. As this article shows, the compensatory strategies incorporated into one community-based, real-Life rehabilitation programme in Philadelphia, Pennsylvania, are as varied as the challenges they seek to address. © 1997 Elsevier Science Ireland Ltd. Keywords: Traumatic brain injury; Compensatory strategies
1. Introduction
A yellow post-it note on the back door reminds the busy executive not to forget his notes for tomorrow's important presentation. A stack of books strategically placed in the middle of the bedroom helps a busy teenager remember her homework for school. Both the yellow note and the stack of books are simple, useful strategies,
* Corresponding author.
designed to help these individuals accomplish a task which is difficult for each of them. For the person with a traumatic brain injury (TBI), the use of compensatory strategies serves the same purpose: to enable the individual to reach a higher consistency of success in performing a task and a higher level of independence than he or she would accomplish without the strategy [1]. Compensatory strategies for the person with TBI are used to overcome barriers and challenges in a wide range of areas - including attention and concentration, memory, behaviour,
1053-8135/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 1053-8135(97)00031-0
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S.M. White et aL / NeuroRehabilitation 9 (1997) 205-212
motor skills and daily living skills. The goal of compensatory strategies is to focus on how these deficits effect the individual and to learn to use the strategies to compensate in real life situations involving work, leisure and social settings. However, unlike the absent-minded executive or the busy teenager, individuals with TBI may not understand that they need strategies, or recognize which situations call for strategy development. Their neurological injuries may have caused diminished awareness in each level of the so-called 'Awareness Pyramid': Intellectual Awareness, the ability to understand that there is a difficulty in the way the person functions; Emergent Awareness, the ability to recognize the problem as it occurs; and Anticipatory Awareness, the ability to anticipate that a problem will occur, as a result of the individual's impairment [2]. In some cases, individuals with TBI may have been injured before their strategy systems were developed or have no memory of specific strategy systems to rely on. Still others will discover that after their brain injuries, the strategies they once used no longer work. This helps explain why the development of compensatory strategies is critical for individuals with TBI. The use of compensatory strategies in rehabilitation 'is based upon the theory of functional adaptation. Functional adaptation assumes that clients need to develop alternative ways to manage deficits [3]. The use of compensatory strategies is extremely important in the rehabilitation of persons with traumatic brain injury. They are taught in therapy sessions and in the community using actual situations of real life as the prototype for strategy development. In one community based, comprehensive rehabilitation programme for individuals with TBI - located just outside Philadelphia - compensatory strategies, restorative treatment and alternative skills are developed for clients in an effort to increase their ability to be independent and live in the community. Persons with brain injury are appropriate for admission to a community based programme when they are medically stable and at a Rancho level of five or above [4]. Because persons with TBI often do not generalize skills well [5], community based rehabilitation is
the best way to ensure that clients implement strategies into their daily lives. Strategy development is based on a strategy hierarchy that accounts for each individual's ability to function independently vs. their need for assistance. And though each client with TBI must deal with certain barriers, the use of strategies seeks to capitalize on each client's particular strengths and works to build new skills in those areas. As this rehabilitation centre near Philadelphia is dedicated to real-life rehabilitation, strategies and alternative skills are developed for every phase of a person's life - from room organization and paying bills to coping in social situations and safely crossing the street on the way to work. 2. Strategy development Depending on the strengths and needs of the client, a strategy can be utilized in many areas of rehabilitation: in restorative treatment, which attempts to help a person reacquire or improve lost skills; or in compensatory skill development, which works around deficits to teach alternative ways to accomplish a specific behaviour. Strategy use is not appropriate for those who are medically unstable or who are undergoing rapid neurological change. Compensatory strategies utilize a person's more intact skills and strengths, breaking a task down step-by-step and utilizing external and internal cues to successfully complete a task [6]. A strategy is defined as the deliberate and consistent use of a carefully designed procedure to reach a goal or accomplish a task which is difficult [1]. Hundreds of strategies have been developed to help individuals with TBI remember to take their medication, cook dinner, catch the bus, mail a letter and water the flowers. No two strategies are alike; rather, each strategy is client-specific, taking into account not only the client's cognitive and physical abilities but his or her personality as well (see Sidebar 1). Consider, for example, the strategy developed for a client named Mark who was frustrated by transfers during his physical therapy sessions. The staff developed a strategy to verbally review three different rationales with Mark before doing the
S.M. White et at. / NeuroRehabilitation 9 (J997) 205-212
transfers. At the conclusion of the strategy was listed the message: 'Do not use the word 'safety'
Strategy sidebar 1 Strategies have been developed in 12 different categories to assist clients with traumatic brain injuries. These categories include: Categories
Available strategies
Communication
Speech intelligibility/pragmatics oral/written comprehension conversation skills following oral/written directions
Self-awareness
Orientation to person, place, time orientation to brain injury barriers comprehension of how brain injury barriers affect daily living situations
Problem solving
Problem solving/decision making in home / community /workplace
Behavior
Management of undesirable behaviors social skills
Substance abuse
Drug and alcohol education Maintenance of sober lifestyle Refusal skills
Time management
Following schedule Planning schedule
Money management
Budgeting Shopping Banking Paying bills
Mobility
Primary mobility skills Pedestrian safety Topographical orientation Use of public transportation
Medical
Self-medication skills Prescription refills Medical appointments
Hygiene/grooming
Personal hygiene Dressing Laundry
Meal preparation
Kitchen safety Meal preparation Menu planning Shopping
Room /house / apt. upkeep
Cleaning Room/apartment organization
207
Strategy sidebar 1 (Continued) Recreation
Leisure options in home and community Participation in leisure activities Recreation planning Socialization
Vocational
Interviewing skills Job training Social skills in the work place
with Mark. He considers it uncool to be concerned about safety'. To help develop each unique strategy, the staff developed these guidelines: •
Recognize that the client 'makes' all the strategies. From the beginning, bring the client into the process of developing a strategy, which helps the client 'own' the idea and be interested in making it work. If the strategy is developed in isolation without client input, it probably won't work. • Prioritize the functional needs of the client. Consider the client's strengths (good attention skills, for example) and barriers (can't retain information). Recognize the total picture of the client's life, including the client's desires, the family's needs and the environmental concerns. Do not overwhelm the client or the family with too many strategies at once. • Analyze the task. Do not just hand the client a checklist and expect results; observe the client's natural approach to the task. People learn and remember better if they are allowed to incorporate what they already know or can do. • Consider the client's learning style. Some clients learn better with written information, some are oral learners and some do best with a combination of both. Incorporate demonstration and pictures into strategies for those who are visual learners. Some clients may have the ability to work with presets (a verbal review with the client before
208
S.M. White et al. / NeuroRehabi/itation 9 (1997) 205-212
he/she starts a task, one that reviews directions or behavioural expectations or both). Help the client develop written or verbal cues that might include such compensatory strategy tools as check lists, key words or recorded messages. Prosthetic memory devices help resolve memory problems with external devices like coloured key jackets, car beepers and whistle activated devices, wrist watches that store phone numbers and names, appointment calendars and electronic pillboxes, to name a few [7]. Such devices do not work for all clients, but are worth considering. •
•
Practice different approaches. Take into account the client's personality, the brain injury barriers, interests and willingness to buy into the strategy implementation. Determine if the strategy is practical. If each strategy takes 3 h and requires one-on-one supervision, chances are it won't be successful for very long. Consider the setting, availability of staffing and help, family concerns and client limitations when developing a strategy.
in implementing strategies. 'Look how far you've come,' is a good way to review past accomplishments, along with praise, rewards and recognition (see Sidebar 2). Implementing any strategy must take into account a client's ability to function independently vs. their need for assistance. In the strategy development hierarchy, the following levels exist: •
•
3. Strategy implementation A client with TBI mayor may not understand why a strategy is necessary, but he or she can typically comprehend what the strategy can help him accomplish and in trying to implement a strategy, connecting the strategy to an intrinsic or extrinsic goal will help a client embrace and use a strategy he may not understand. Strategies, for instance, can be linked to life goals or discharge placement plans. Strategies that help a client travel to a community centre may enable the client to meet new friends, which is often a major goal of clients with TBI who experience social isolation. A work-related strategy may help a client get a job and strategies that help clients adopt independent living skills such as getting dressed, cooking and balancing a checkbook may help these clients realize their goal of living on their own. Ask the client directly, 'What do you want most?' and then review how different strategies can help him meet these goals. Motivating the client to be proud of his progress is a key factor
Staff based, environmental. In this level, clients do nothing voluntarily to carry out a strategy. They rely on maximum assistance from staff for constant supervision and cueing. It is the staffs tone of voice, cueing systems and environment (quiet room with limited distractions, for example) that make the strategy successful. Because the client is not aware that strategies are effective, he relies totally on the staff to help him respond to the environment with appropriate, learned strategies. Staff and client based. At this level, both staff and client have a role in making the use of strategies successful. The client begins to understand that they actually need to use strategies to reach a goal. This awareness is key to
Strategy sidebar 2 When using compensatory strategies with clients, it is helpful to remember the following: Do:
Use cueing hierarchy (maximum-minimumindependent use). Ask questions to clarify strategy rationale or steps. Provide rationale to client. Remain positive and patient. Recognize that some trial and error may need to occur. Be aware of your own non-verbal communication and its impact on the client. Communicate failure/success of strategy to other staff. Review /revise strategy frequently to increase effectiveness.
Don't:
assume strategy will always work. Expect success quickly. Sabotage by improvising your own strategy instructions. Be afraid to refer to written strategy with client. Get into a power struggle with client. Take conflicts personally.
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their use of strategies in a more independent manner. In this level, the staff will preset a client to use a checklist for shopping. The client will be given cues to use the list. However, it is the client's role to make sure he uses the list when shopping. Moderate cueing - checking back in with a client on an intermittent basis - is critical at this level. Client based. When the client reaches this level, he is able to initiate and monitor his own strategies. The client may need help to problem-solve or to recognize when a strategy no longer works, but he initiates the use of strategies at appropriate times. This level of self-awareness allows the client to live a more independent lifestyle.
4. Role of awareness in strategy development Level of awareness and severity of deficits both play major roles in determining the level of support necessary for successful implementation of a strategy. It is the client's awareness of deficits and the client's ability to understand how these deficits affect daily life that is the critical element in determining how independently a person can use or generalize a particular strategy [2]. Use of a rationale is often critical to a client's acceptance of a strategy. For persons with diminished awareness, rationales provide an explanation of which brain injury barriers are preventing successful completion of a task or interaction and how the use of a particular strategy can promote success. An example of this is a rationale of a time management strategy written for Ben: 'Ben, you do a great job getting showered, dressed and breakfast completed each morning, but you get easily distracted by other things in your apartment and this often makes you late. Use of a timer and a checklist help to keep you on track so you can get to work on time and can be successful at your new job'.
Dependent upon the person's needs, a rationale may be reviewed with the client as a preset immediately prior to strategy use, reviewed on a daily or weekly basis with family or staff, or be reviewed independently by the client on his own. Rationales are also useful for staff or family
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members. They remind the caregiver what the purpose of the strategy is and why the strategy is important for client success. 5. Examples The following strategies have been developed for different clients with traumatic brain injuries. Each strategy includes a goal that is important for each client. 5.1. Strategy 1: topographical orientation in community 5.1.1. Treatment / discharge focus: mobility 5.1.1.1. Rationale. James has difficulty organizing verbal directions when traveling to unfamiliar destinations in the community. These recommendations will assist James in traveling in the community. 5.1.1.2. When / how strategy should be used. James should work with staff for each new destination and continue to be supervised by staff until he demonstrates independence in initiating and carrying through with the strategy without any staff intervention. James should review this strategy prior to gathering any information or directions to a new destination. 5.1.1.3. Recommendations for James.
1. Copy down phone numbers and address for destination. You will need this if you get lost. 2. Gather as much information as possible not only for what streets and directions to tum but also distances between turns and landmarks prior to a tum. For example: • After Bala Shopping Center, look for Montgomery Avenue. • At Montgomery Avenue, tum right. 3. Write down directions in step-by-step format. Do not use a paragraph form. 4. Keep directions concise and to the point. For example: • At the second light, tum left. • Go approximately about 3 miles and look for the Sunoco. • First light after the Sunoco (Fairview Avenue), tum left.
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5. Prior to starting back from your destination, rewrite the directions for returning. 6. Keep your directions in your Direction Notebook. 5.1.1.4. Recommendations for staff. Check directions for accuracy and use of correct format. 2. Accompany James on the route the first time. If he does not require any staff assistance, then he will be cleared to travel that particular route. Staff should continue to accompany him on a route until he has demonstrated independence. 1.
5.2. Strategy 2: cooking dinner 5.2.1. Treatment/discharge focus: cooking safety 5.2.1.1. Rationale. Amy does not always follow recipes accurately, follow general safety principles or remember to set the timer. Amy has agreed to use a timer and review lists in order for her to learn to cook safely and more independently. 5.2.1.2. When / how strategy should be used. For Monday, Thursday and Friday dinners. Amy uses the microwave independently on Tuesday, Wednesday and Saturday. 5.2.1.3. Time needed to use / complete strategy. Sixty minutes. 5.2.1.4. Amount of assistance needed. Maximum cueing to review safety lists. Minimum assistance during cooking process. 5.2.1.5. Procedure.
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Staff should cue Amy to review safety tips and cooking and baking steps posted on the side of the refrigerator before cooking in order to cook more independently and safely. Some sample lists include: Safety tips • Use scissors to open packets, not knives. • Cook one thing at a time. • Tum pot handles in when on stove top. Cooking and baking tips • Read through recipe directions completely.
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Gather all ingredients. Preheat oven (remove plastic and paper from stove top). 2. Staff should tell Amy that they will be filling out a cooking checklist after cooking with her and that the checklist will be reviewed after 2 weeks. If Amy does well, she will be able to cook more independently. The cooking checklist includes the following items: • Amy reviewed safety and cooking steps prior to cooking with staff. • Amy accurately followed recipe measurements without help. • Amy accurately followed recipe directions without help. • Amy removed all flammable objects from the stove top without staff cues. 3. Once lists are reviewed, staff should avoid helping or cueing Amy unless she is not safe or asks for help. Before jumping in to help, see if she can correct mistakes herself or figure out what to do. 4. Staff should fill out cooking checklist in the back of the menu planner binder after meal preparation. 5.3. Strategy 3: dressing packets
5.3.1. Treatment/discharge focus: hygiene / grooming 5.3.1.1. Rationale. Due to organization and memory barriers, Paul has difficulty organizing his clothes each morning. This strategy is designed to help Paul keep together all the clothes that he needs for the next day so that he can dress independently. 5.3.1.2. When / how strategy should be used. On laundry day. 5.3.1.3. Time needed to use / complete strategy. Ninety minutes for Paul, 30 min for staff. 5.3.1.4. Amount of assistance needed. Minimal. 5.3.1.5. Procedure On laundry day, Paul should fold all clean clothes and leave them on the bed. 2. Staff should arrange clothes into piles: pants, shirts, socks and underwear. 3. Paul should take one piece of clothing from 1.
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each pile and pack them into a clothing bag until seven bags are completed. 4. Staff should check for colour coordination and to make sure all packets are completed. 5. Paul should put completed clothing packets in the dresser (top two drawers). 6. Each night during the evening routine, staff will check with Paul to make sure there is a clothing packet available for the next day. Note: any extra clothing should be kept in the bottom drawer for variety. Staff can pull out clothing from this drawer to exchange with the ones Paul has been wearing for a while. 5.4. Strategy 4: communicating with adult family members
5.4.1. Treatment/discharge focus: social skills 5.4.1.2. Rationale. In communication, taking turns during conversations is required to avoid conflict and to allow for positive/nurturing results. Communicating in this manner helps John avoid 'shut down' or 'outburst' reactions to tense situations. John has developed this strategy with his speech therapist and has agreed to follow it for the next 2 weeks to see how it works. 5.4.1.3. When/how strategy should be used. When conversations are becoming tense. 5.4.1.4. Procedures. The following steps will be followed when an interaction is becoming tense for John or another family member: John or a family member will state 'Please be quiet and listen', or 'I'm becoming upset, do you mind if we continue this later?' or 'I'm feeling tense, what about you? Can we start over?' 2. If the conversation continues, John and the family member will agree to take turns. 3. Each will speak, and the other will listen. 4. Both should move to a quiet place to decrease distractions or simply sit to continue the discussion. 5. A compromise or a simple 'agreement-to-disagree' are positive ways to end the conversation. Both may also agree to try to work it out later. 1.
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6. Conclusion Strategies make everyone more successful and the success of every strategy depends on many factors, including the awareness level of each client and the amount of practise and repetition allowed for each strategy. One key element necessary for successful implementation is staff monitoring, with constant evaluation of the strategy and on-going assessment once it becomes successful. When evaluating a strategy, staff need to remember that most strategies are not immediatly successful. Develop goals to help determine how long it should take for the client to use the strategy successfully with different levels of assistance. Remember that trial and error is expected in mastering the strategy and that good communication between the developer of the strategy and the user of the strategy is essential. Sometimes, strategies fall apart, and it is up to the staff to evaluate what went wrong and develop a new strategy for the client. It is important to remember that clients do not always make progress. It is acceptable for clients to stay at one level within a strategy progression, particularly if there are other changes in the client's life. Staff assessment may sometimes determine that more assistance is necessary to make the strategy successful or to help the client reach a higher consistency of success in performing a task before proceeding to a higher level of independence. Once a strategy is considered successful, an on-going assessment is critical. Questions to consider include: is the strategy still working? Can the client progress to a more independent level? Should the strategy be modified to meet the changing needs of the client's environment or a change in lifestyle, moods and medical status? In our experience, strategies are most successful when they are developed in a setting similar to the one where it will be used - be it at home, at work or in the community. In these settings, the person with TBI can develop awareness of barriers and see how the use of strategies can positively impact daily life in real life situations.
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[5] Gobble, EMR, Ylvasaker M. 'Community reentry for head injured adults'. Little Brown and Company, 1987:107. [6] Milton SB. Compensatory memory strategy training: a practical approach for managing persisting memory prob· lems. Cogn Rehabil Nov/Dec 1985:8-15. [7] Parente F, Anderson·Parente J. 'Retraining memory techniques and applications'. CSY Publishing, 1991: 175-191.
