Developing Motivation

1
Developing Motivation Self Awareness After
TBI 25 Approaches

• Gerry Brooks, MA, CCC, CBIST
• Director of Brain Injury Programs
• Northeast Center for Special Care
• 300 Grant Avenue
• Lake Katrine, NY 12449
• www.northeastcenter.com

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Rehab in the U.S.

• Reimbursement exhausted weeks/months post onset
• Two steps Acute rehab?Outpatient rehab
• Belief that most recovery occurs first 3-6 months

3
Rehabilitation in a Nursing Home

• Individuals may be referred to a nursing home for
  continued rehab
• Non-specialized
• No special funding/resources
• Ill-equipped for cognitive-behavioral rehab

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5 Case Illustrations
5
Case 1

• 22 year old male
• Single, no children
• Graduated H.S. early with honors
• 2 years of college
• Licensed stockbroker
• TBI/MVA

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Case 1 Continued

• LOC 3 Weeks
• Month 1 Acute Rehab
• Month 3 Brief admission to
• other nursing home
• Month 3 Mother takes him home
• dissatisfied with treatment

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Case 1 Continued

• Month 8 E.R. Visit, He needs more rehab
• Awake, alert, unsteady gait, speech relevant,
  coherent, disoriented to time, age, DOB, address
  problems with retention, recall, calculation,
  comprehension, impulse control
• Losing way around home community

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Case 1 Continued

• Admitted to hospital
• Intermittent urinary incontinence
• Offering no complaints
• 1 to 1 attendant maintained
• 1 month uneventful inpatient stay

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Case 1 Continued

• Admitted 9 months post injury
• Flat, confused, disorganized, disheveled,
  dependent, severe abulia
• Misidentification delusion

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Case 2

• 50 year old male, Factory owner
• Married, College educated
• TBI/struck by fragment from machine
• LOC Brief (minutes)
• Lost R eye bi-frontal contusions, R frontal
  lobectomy

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Case 2 Continued

• Several weeks acute rehab, then home
• Month 4 Hospitalized for abrupt behavioral
  decline
• Hydrocephalus, seizures, ventriculitis

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Case 2 Continued

• 4 transfers in 6 months
• Month 6 Acute rehab
• Month 8 Nursing home
• Month 9 Hospital
• Month 10 Acute rehab
• 2 shunts with multiple revisions
• RLA V (from VII)

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Case 2 Continued

• Admitted to program 11 months post
• Fluent, non aphasic speech, completely
  confabulated, anosagnostic
• Antagonistic to spouse, withdrawn,
• depressed, resistive, argumentative

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Case 3

• 39 year old unmarried male
• Auto and airline mechanic
• Expelled 9th grade - truancy
• H/o ETOH, sober X 2 years
• TBI - hit by truck at 45 mph
• LOC Yes, ?duration
• Pre-morbid concussion X 3 MC accidents

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Case 3 Continued

• L AKA (pre-onset, congenital condition)
• R BKA (post-onset)
• Completed acute rehab

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Case 3 Continued

• Admitted 4 months post injury
• Mild fluent aphasia, confused, restless,
  non-compliant

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Case 4

• 44 year old male
• Separated, 3 y.o. daughter
• 10th Grade education, L.D., aggression, possible
  bipolar, cocaine, ETOH
• No work history, prominent family
• TBI/assault
• Prior CHI/fall without sequelae

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Case 4 Continued

• Admitted 7 months post injury
• Non-communicative, non ambulatory, severely
  aggressive, total care

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Case 5

• 44 year old female nurse on disability
• Married with children
• Premorbid brittle IDDM, hypothyroidism, asthma
• 6 hour episode of hypoglycemia
• LOC X several days CT No acute lesion
• Acute rehab without effect

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Case 5 Continued

• Admitted 8 months post injury
• Mute, no interaction, labile, hyperactive,
  incontinent, total care

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Summary
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Relevance

• Cases not unique
• They illustrate
• Limits of prognosis
• Limits of reimbursement
• Promising clinical practices

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Source

• Northeast Center for Special Care
• 280 bed post acute facility
• 209,000 sq ft therapeutic community
• Designed specifically for brain injury
  rehabilitation
• Moderate-Severely Impaired
• Mostly male, average age 40s
• 10th year of operation

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Why did they progress?

• They had potential

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• Open, supportive,
• interaction-rich community
• with many things to do

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• A living community, Cafe, Post Office, Store,
  Bank, Hair Salon, Gymnasium, Art Studio, Music
  Studio...

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• Rich, natural, continuous...

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• ...daily, supported opportunities for engagement.

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• Absent expectation that progress will be linear
• i.e., progress will not necessarily occur in
• a reasonable, predictable period of time.

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• Use of Psychosocial Prosthetics
• Staff trained and continually evaluated for how
  well and continuously they engage
• Maximizing arousal, attention, mood, doing

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• Impaired motivation regarded as
• a primary treatment target
• (vs. a criterion
• for discharge)

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Calling Dr. Freud

• Write down the first 5 words
• you associate with
• Motivation

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Some web definitions

• The tendency of an animal to engage in a
  particular behaviour, e.g., a feeding motivation
  or a sexual motivation.openlearn.open.ac.uk/mod/g
  lossary/view.php

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• The ability to do something and to keep going
  even when things get difficult.kids.direct.gov.uk
  /resource_areas/html/glossary/lmno.htm

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• Desire to accomplish a goal or participate in an
  endeavor.www.sparkle.usu.edu/glossary/index.asp

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• Feelings that drive someone toward a particular
  objective.www.crfonline.org/orc/glossary/m.html

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• The positive or negative needs, goals, desires
  and forces that impel an individual toward or
  away from certain actions, activities, objects or
  conditions. The inner needs and wants of an
  individual what affects behavior.www.marketingnew
  s.co.in/glossary/4

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• The need or desire that determines an
  individuals effort, behaviours
• and actions.www.businessstudysolutions.com/glossa
  rym.htm

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• "Motivation" is the third single from the album
  All Killer No Filler by the Canadian
  pop-punk/Punk rock band Sum 41. The song is about
  being self-centered, demotivated and lazy, too
  lazy to look for motivation to do anything.
  en.wikipedia.org/wiki/Motivation (song)

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What is the common denominator?
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• Johns Story

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• What does John lack?

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• He could not see how his present actions related
  to his future
• What was explained he could not retain

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As a result

• He lacked motivation

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But did John lack desire?

• No way.

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Desire

• We may know we need to do something, and do it,
  without desiring it.
• We may desire something we do not pursue.

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Axiom No. 1

• Motivation Desire, Insight, and Expectation of
  Success (Hope)
• Corollaries(1) It requires cognitive ability (2)
  it requires a history of success, lots of
  support, or both

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Axiom No. 2

• Insight is more than knowledge
• Its an active process of making judgments using
  knowledge, past experience, up-to-date awareness
  of resources and opportunities. Without it there
  is no ability to plan, to evaluate, to adjust
  there is no ability to avoid doing something
  shortsighted or to persist in the face of
  difficulty.
• Corollary Degree of Motivation Disability is
  correlated with severity of the brain injury

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Axiom No. 3

• Motivation Alone
• Doesnt Guarantee Success.
• Success requires commitment, skill, opportunity,
  insightand a little bit of luck could never
  hurt.
• Corollary No one can do whatever they put their
  mind toso stop asking

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Axiom No. 4

• No one is independent.
• Nobody succeeds on their own.
• Corollaries(1) God does not limit his or her
  help to those who can help themselves (2) Its
  awfully hard to accept help when (a) its
  considered a sign of weakness and (b) an absence
  of virtue

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The Basis of Insight

• is the capacity to reflect

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Question What is reflection?Answer It is the
ability to see
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Reflection in action

• Did you want (desire) to get out of bed this
  morning?
• How did you do it then?

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You Reflected

• On consequences (future)
• Based on experience (past)
• You felt those consequences as if they were real

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Even in your groggy state...

• Your mind connected past,
• present, and future.

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Reflection ? Awareness

• This
• hovering awareness
• is ongoingeven now.

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Want proof?

• Thought of something else while you are listening
  to me?
• Agreed or disagreed with something Ive said?
• Flashed on later today, tonite, this weekend?

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Its no joke

• its a fact You are not all there,
• but its quite normal!

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Obsessively mind-full are we

• Of what we are doing
• Of what we did
• Of whats next
• And within arms reach
• Past experience
• Future expectations

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Brain injury reduces awareness by reducing
capacity to reflect

• Past Present Future
• --------------noTBI----------------
• ------------mTBI-------------
• -------modTBI-------
• -----sTBI----

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Loss of awareness isnt

• Loss of knowledge, information,
• or memory (necessarily)

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It is loss of the ability to see

• Past, present, and future as linked
• In real time
• The ground of awareness to figure of our
  immediate actions
• You see?

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Because we can see the link

• (in real time)
• We resist (impulses)
• We persist (at what we must do)

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Other major contributions

• Loss of support
• Memory deficits
• Loss of structure and related automaticity
• Reduced opportunity
• Catastrophic reaction/Downshifting
• Behavioral disturbances

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Associated Clinical Conditions

• Some terms and clinical conditions associated
  with Disorders of Awareness and Motivation
• Abulia, adynamia, anosagnosia, apathy,
  aspontaneity, confusion, depression,
  disinhibition, disorientation, executive
  dyscontrol, flat affect, frontal lobe syndrome,
  impulsiveness, memory impairment,

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• 25 Ways to Help Improve Self
• Awareness and Motivation

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But first,

• Lets take a 30 second
• stretch break!

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Note

• Not everything that follows is for every setting
• Take what makes sense and adapt it
• Comments concerning children welcome as we
  proceed
• Order of information is generally from more
  simple to more complex earlier to later
  treatment issues

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1. Target Motivation

• Motivation disability is a reason to treatnot a
  reason to discharge
• Building motivation
• context of treatment (the people, the
  environment, the other activities available)
• and content of treatment

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2. Reduce interfering Behaviors

• Behaviors are a symptom
• Dont neglect the causes
• Setting Conditions
• Triggers
• Functions

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Treating Causes of Challenging Behavior

• Setting Conditions How many things that
  contribute to misery can be reduced how many
  things that bring joy can be added.
• Triggers How many things that set the person off
  can be avoided
• Functions How can we help the person accomplish
  the same thing as their behavior in another way?
• NOTE There is no magic bullet

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Major Setting Conditions

• Fear/Security
• Worthlessness/Value
• Confusion/Clarity
• Physical Disability/Ability
• Loneliness/Friendship
• Lack of/Opportunity

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Triggers

• No more/less than everyday stresses
• Relevant only because person is already under too
  much stress
• Avoid or Eliminate

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Major Functions

• Acquire or avoid loss of control, power, control,
  or status
• Avoidance of failure (Anything less than perfect
  may failure when a person feels so diminished
  already)
• Acquire reassurance that someone cares, that I
  matter or validate that no one does and I dont
• Communicate the depth of pain

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3. Maximize energy

• Arousal system may be damaged
• Sleep and awakeness may both be impaired
• Sleep tracking/self journal to evaluate sleep
• Actigraphy and medical sleep evaluation
• Sleep hygiene (1,2)
• Medications
• Exercise and Diet
• 1. www.discoveryhealth.queendom/sleep_hygiene_abri
  dged_access.html
• 2. www.sleepfoundation.org/site/c.huIXKjM0IxF/b.24
  22637/k.5B7/
• Ask_the_Sleep_Expert_Sleep_Hygiene.htm

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4. Maximize Attention

• Dont assume itcant tell by looking
• Re-alerting
• Require active responses
• Chunking
• Natural activities vs. attention therapies
• Medications

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5. Re-Orient

• FacesAn album of VIPs in persons life
• PlacesPoint to point wayfinding
• Routine

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Importance of Routine

• We structure our lives
• Organize them around more or less automatic
  routines
• Speeds decision making, reduces anxiety,
  conserves resources

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How functional are you when

• Your shoelace breaks
• Your car wont start
• Your child is home sick
• Theres an accident blocking the road
• How good is our executive controlreally?

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6. Establishing Routine

• Create a routine and stick to it (it will be
  harder for you)
• Posted Schedules
• Anticipation shelves
• Note Its not a routine until the individual
  can anticipate boredom may be a good sign!

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Routines within Routines

• Develop
• Get up routine
• Get dressed routine
• Get breakfast routine
• Get to work/school routine
• Etc., etc.

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7. Mood Regulation

• Fronto-limbic system emotional thermostat
• Impairment common with frontal injuries
• Self regulation traininggreen, yellow, red
• Self Calming methods5 breath method
• Auto-arousal training
• Therapeutic narratives to stabilize mood
• http//www.northeastcenter.com/therapeutic_narrat
  ives_neurobehavioral_disorders.htm

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8. Nonverbal communication as mood stabilization

• You have the power
• Facial expression
• Tone of voice
• Body movements and position

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9. Medication management

• The balancing act
• (?) Avoid sedation
• (?) Enhance cognition
• (?) Stabilize behavior
• (?) Treat addiction
• Brain Injury Medicine, Zasler, Katz, Zafonte,
  2007
• Demos publishing company, LLC, 386 Park Avenue
• South, New York, NY 10016

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Types

• Mood stabilizers (Depakote, inderal)
• Antidepressant/Anti-anxiety (Zoloft, luvox)
• AntipsychoticsRespiradol, seroquel
• PsychostimulantsProvigil, ritalin

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10. Consider stress inoculation

• Physical/cognitive effects of stress
• Coping strategies Rehearsal
• Progressive desensitization to
• triggers
• http//www.apa.org/divisions/div12/rev_est/sit_str
  ess.html

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11. Create a Therapeutic Relationship

• Your Relationship Your interaction history
• We like people who seem to like us
• What every salesperson, politician, and con
  man/woman knows
• Goal The power to persuade

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Important Concepts

• Its not what you say but
• Power, likingness, attraction
• We all pay far more attention to it than to words
• A person with a B.I. may read it better
• That may be all they are reading

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• Talk up
• Look for chances to re-direct, cue, remind, or
  prompt
• Your nonverbal signals must communicate you are
  safe, you matter to me, no matter what is being
  thrown at you
• Expect reductions in disruptive behaviors
• Easy to understand, hard to do

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Every interaction is the most important one

• Over mood, thought, communication, trust
• With great power
• Every interaction either hurts or helps ... no in
  between

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Relate to strength vs. weakness

• You must be the hope he or she lacks
• What do they hear in your voice?
• What do they see in your eyes?
• Empathy with Hope or sympathy and pity?
• Are you a victim or a survivor?

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12. Manage the Milieu

• Milieuthe social environment the moment-to-
  moment interactions that occur around and with
  the person
• Multiplying effect of incidental interactions
• Neuropsychosocial support
• Widespread therapeutic interaction training a
  must
• For further reading See http//northeastcenter.c
  om/information-bulletin-therapeutic-community-tbi.
  htm
• Neuropsychosocial Intervention by Robert Karol,
  PhD the work of Kurt Goldstein re Catastrophic
  Reaction Yehuda Ben-Yishay and Leonard Diller
  on Holistic Rehabilitation

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Staff Training Essentials

• Dont do what comes naturally rule. If youre
  interacting without paying attention to your
  facial expression, tone of voice, and body
  posture, you are probably hurting, not helping
• Smile-greet-engage rule. If you are not
  clearly positive, you will be read as being
  clearly negative
• No passing rule Never pass without some
  positive engagement
• How to adapt to cognitive limitations (stand by)

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13. Train the family

• How to provide quality support
• Early and often--role distortion and abandonment
  is common
• Explain motivation disability
• Facilitate natural vs. therapist
• role
• Promote importance of their well-being

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14. Adapting to Cognitive Limitations

• You know this but do they?
• Slow down everything
• Say less, listen more
• Build slowly on repeated basics
• Continual re-arousal, active response
• Hand outs, bullets, sub/super/co-ordination
• Preview-review

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More adaptations

• Overcommunicate, Dont assume understanding or
  retention
• Be delighted to repeat, encourage asking
• Keep explanations simple
• Speak in bulletse.g., giving directions,
• 2nd floor
• Left
• Left
• Ask for return explanationorganization occurs at
  output

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Generalization of new skills

• New skills will require practice in real life
  situations
• No substitute for good coaching
• See also Re-Training Cognition Techniques and
  Applications by Parente and Herrmann

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15. Leverage Relationships

• A therapeutic relationship should motivate
• Use it
• The value of extrinsic motivation
• Gradual return of units of responsibility
• Responsibility for selfappearance, belongings,
  behavior, doingwhat?

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16. (Re) Engagement Therapy

• Working with vs. against natural interests
• Exploring strengths
• Need opportunities for varied, frequent,
  accessible, natural, enjoyable activities
• Fun may need to precede serious therapies (or
  formal education)

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• Selection of activities based on interest and
  aptitude
• If taken seriously (by you)?
• Gives status and
• Self-esteem
• Becomes self-reinforcing over time

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Goals of (Re) Engagement

• Promote doing (opportunity to develop skills)
• Leading vs. following
• Dependence?Interdependence
• Staff mediation?Self mediation
• Empowerment Victim?Survivor (expect resistance)

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17. Intention Strategies Basic

• Pleasing you may be the only motivation here
• Following a Schedule?Creating own Schedule
• Checklists/To do-Done Systems
• Task Completion Strategies
• Prepare all the steps in advance
• Lie out pieces/implements/ingredients in order to
  be used
• Leave a reminder of what you were working on if
  you leave a workspace
• Use of interval timer to keep track of schedule

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18. Intention Strategies Intermediate

• Motivation starts to be about wanting to do
  something
• Exploration of things the person might like,
  eventually love (avocational rehabilitation)
• No excusesfor us or the individual
• Leveraging comes in big time here
• Working toward vs. working on (link to future)

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Electronic Aids

• Palm pilots
• Timex data-link watches (1)
• PEAT (2)
• 1.http//www.timex.com
• 2. http//www.brainaid.com
• 3. Sohlberg, M. M., Kennedy, M. R. T., Avery, J.,
  Coelho, C., Turkstra, L., Ylvisaker, M.,
  Yorkston, K. (2007). Evidence based practice for
  the use of external aids as a memory
  rehabilitation technique. Journal of Medical
  Speech Pathology, 15 (1).

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19. Advanced Strategies

• Self Managed Preview/Review-Re-Write
• Manage time
• Manage information
• Manage money
• Promotes
• Reflection and evaluation
• Organization and memory
• Insight and judgment
• Prioritization and planning

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20. Goal maps

• Concretization of steps toward goal
• Simple schematic
• Brings individual/staff/family literally onto the
  same page
• Mantras that everyone reinforces

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• PLAN MY DAY?
• WORK MY PLAN?

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Eves Map

• Stay on Track Stay connected
• Master community mobility
• Take an adult education class
• Evaluate music school plan

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21. (Re) Establish NarrativeSelf -Awareness

• Ability to talk about self reflects
  self-awareness
• Re-orientation in most meaningful sense
• Identity in its most basic sense

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Axiom 3 Re-Visited

• Insight is more than
• knowledge.
• In order to be useful, insight must occur to you
  when you need it so you can avoid doing something
  shortsighted and do something you should even
  though it is difficult.

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Steps

• Therapist-created (at first)
• Narrative linking selected facts from the
  individuals past, present, a future goal, plan
  for attainment
• Written in first person

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Steps, Continued

• Read fluently, with interest
• Read with meaning
• Fill-in-the blanks
• With word bank
• Without word bank
• Explained from outline only

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Steps, Continued

• Formal presentation to peers, significant
  others--key word outline only
• Organization occurs at output
• --Parente
• Re-formatting the hard drive

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Added benefits

• Improved memory
• Improved processing
• Improved communication skills
• Improved calm clarity
• Improved motivation

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22. Problem Solving Strategies

• SODAS (1,2) method of problem solving
• Teach it to S.O.s, family, sponsors
• Teach Checking in with a mentor (or sponsor)
• 1.Handout http//www.pki.nebraska.edu/studentinfo
  /simp/mentoring_guide/SODAS20Text.pdf
• 2. Curriculum http//tip.fmhi.usf.edu/files/TRAIN
  ING-Module5-SODAS.pdf

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23. Disability Education

• About brains and brain injury
• Neurologic disability vs. mental retardation
  vs. psychiatric disorder

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24. Team Intervention

• What it ispowerful!
• What it does
• Connects the dots and the people
• Solidarity and support
• Empowerment and commitment
• Tie what is discussed back to goal maps

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25. Target Well-being Mastery as an Ideal Final
Outcome

• Subjective Well-being vs. just Objective Wellness
• Mastery of the art vs. just disability reduction
• A framework for recovery
• Means of avoiding/reducing the effects of the
  awareness dilemma

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Ultimate Recovery

• Accepting that joy is created not found
• Taking responsibility to do so

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Well-being Practice

• Relaxation
• Mindfulness
• Sleep
• Eat
• Play

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• Exercise
• Friendship (see BetterTogether.org)
• Avocation--Exploration of talents, find something
  you love to do...and do it regularly
• Letting go of your anger by noticing how hard
  youre holding on to it
• Celebration of successes and gratitude

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26. Community Alliances

• Success re-integration into community
• The community itself is a barrier
• Host opportunities for individuals based on
  interests, e.g., clubs, teams, church groups,
  etc.
• Identification of a mentor within the
  organization
• Advocacy for Change
• A Manual for Action, Al Condeluci, Ed.D.
• (http//www.ancor.org/benefits/pubs.cfm)

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• The End
• Thank you!
• Gerry Brooks, MA, CCC, CBIST
• Director of Brain Injury Programs
• Northeast Center for Special Care
• 300 Grant Avenue
• Lake Katrine, NY 12449
• gbrooks_at_hcany.com
• http//www.northeastcenter.com/