www.scssconsulting.org

Grandma Masse’s Rules Grandma Masse’s Rules for Success:for Success:

““The smart guys are the guys who learnThe smart guys are the guys who learnfrom the other guys. Don’t get all from the other guys. Don’t get all

caught caught up in one thing; everyone believes up in one thing; everyone believes

their thing is their thing is the best thing and they’re usually the best thing and they’re usually

wrong.wrong. So, shut-up and listen and learn and So, shut-up and listen and learn and

change.”change.”

In order to be successful In order to be successful you’ve got to be eclectic.you’ve got to be eclectic.

More Grandma MasseMore Grandma Masse

““Models collect dust on Models collect dust on shelves.”shelves.”

Don’t fall in love with a particular Don’t fall in love with a particular approach – approach –

ideally, you’ll/we’llideally, you’ll/we’llcreate a framework for intervention (a create a framework for intervention (a

working theory) that will evolve with working theory) that will evolve with experience and evidenceexperience and evidence

So, why is self-regulation So, why is self-regulation so important?so important?

Socially Unacceptable BehaviorSocially Unacceptable Behavior

AggressionAggression

Impulsive BehaviorImpulsive Behavior

The Ultimate Result of Impaired Self-The Ultimate Result of Impaired Self-RegulationRegulation

Context Relevancy:Context Relevancy:How does this stuff apply to

the bigger world?adapted from Sailor, 1999

• Useful:Useful: Do the outcomes that we’re targeting produce something useful to the individual in long run?

• Desirable:Desirable: Does the individual choose the outcomes for him/herself when given the choice? Is the individual given thechoice of outcome?

• Social:Social: Do the outcomes result in behaviors that will increase interactions with persons other than paid staff?

• Practical:Practical: Will the behavior be used in real contexts without staff support?

• Adaptable:Adaptable: Is there a focus on developing skills that can/will be used in a number of situations and without staff?

Most of the stuff that works is Most of the stuff that works is conceptually simpleconceptually simple but but procedurally procedurally difficultdifficult. .

In many ways good intervention is In many ways good intervention is really about the systematic application really about the systematic application of common-sense. of common-sense.

Unfortunately, “common-sense is Unfortunately, “common-sense is terribly uncommon.” terribly uncommon.” – Mark Twain– Mark Twain

Three Beliefs That Will Affect the Likelihood Three Beliefs That Will Affect the Likelihood That You’ll Be SuccessfulThat You’ll Be Successful

Optimism & HopeOptimism & Hope. Evident in the problems that are . Evident in the problems that are targeted and the language that is used when targeted and the language that is used when describing the individual and when interacting with the describing the individual and when interacting with the individual.individual.

Appreciating the Influences of Contextual Factors Appreciating the Influences of Contextual Factors on Behavioron Behavior. Requiring an understanding of the . Requiring an understanding of the setting events (the distant events on an individual’s setting events (the distant events on an individual’s behavior).behavior).

Applied PragmatismApplied Pragmatism. Recognizing that there is no . Recognizing that there is no single “right” solution; moving away from the notion of single “right” solution; moving away from the notion of “consistent” use of a prescribed intervention strategy “consistent” use of a prescribed intervention strategy to “concordance” on the part of all involved.to “concordance” on the part of all involved.

Introduction toIntroduction to

Intervention Ideas:Intervention Ideas:Conceptually Simple,Conceptually Simple,

Procedurally DifficultProcedurally Difficult

Why Do I Keep Making the Same Why Do I Keep Making the Same Mistakes? Mistakes?

Why doesn’t it Get Better?Why doesn’t it Get Better?

CognitionCognition

CommunicationCommunication

BehaviorBehavior

BEHAVIOR

ExcessesImpulsivenessAggressivenessSubstance Abuse

DeficitsInitiation ImpairmentsInsight Impairments

COMMUNICATION

EfficiencyFluency/ArticulationDiscourse

EffectivenessFunctionalApparent

COGNITION

Organization Memory Info ProcessingPlanning Procedural vs. Declarative Non-strategicSelf Monitoring Implicit vs. ExplicitReviewingSelf-evaluating

Behavior Interventions that Focus on the Application of Consequences are

Dependent Upon:

HIGH REASON (Intellect – “cool”)

_ “Choosing the best option” _ Logical application of learned

outcomes

For the Most Part,

We Live in the Somatic World:

VISCERAL RESPONSES (Gut feelings – “hot”)

_ “I don’t know why! I just did.” _ Implicit application of experiences

Success via Learning fromSuccess via Learning from ConsequencesConsequencesPresupposes:Presupposes:

Reasonable intactness of the neural Reasonable intactness of the neural networks responsible for connecting:networks responsible for connecting:

Memory for the factual aspects of past behaviorMemory for the factual aspects of past behavior

and/orand/or

Memory for the “Somatic Markers”, or the Memory for the “Somatic Markers”, or the feeling states associated with the consequences feeling states associated with the consequences of those behaviorsof those behaviors

Without these connections in memory, Without these connections in memory, past rewards and punishments past rewards and punishments

lack the power to drive future lack the power to drive future behaviorbehavior

An impulse An impulse

is is notnot

a choicea choice

When choice is offered, of course, it is When choice is offered, of course, it is essential that the person being offered essential that the person being offered

the choice have the information the choice have the information necessary for making a meaningful necessary for making a meaningful

decision . . . without such information, decision . . . without such information, being given a choice will feel more like being given a choice will feel more like a burden than a support for autonomy.a burden than a support for autonomy.

- Edward Deci, 1995Edward Deci, 1995

Why We Do What We DoWhy We Do What We Do

Each waking day is a stage dominated for the Each waking day is a stage dominated for the good or ill, in comedy, farce, or tragedy, by a good or ill, in comedy, farce, or tragedy, by a dramatis personadramatis persona, the “self”. And so it will be , the “self”. And so it will be until the curtain drops . . . Although multiple until the curtain drops . . . Although multiple aspects characterize the conscious self, this aspects characterize the conscious self, this

self is a unity.”self is a unity.”

- Charles Sherrington, 1946- Charles Sherrington, 1946

The Integrative Action of the Nervous SystemThe Integrative Action of the Nervous System

Alliances are Critical to SuccessAlliances are Critical to Success

1.1. When working with others in a concordant manner the When working with others in a concordant manner the intensity, consistency, and duration of services intensity, consistency, and duration of services improves.improves.

2.2. There is an increase in the probability of generalization There is an increase in the probability of generalization and maintenance of positive change (Brown’s Rule of and maintenance of positive change (Brown’s Rule of Three: Three people, three places, three times.)Three: Three people, three places, three times.)

3.3. There is a necessary infusion of reality, common-There is a necessary infusion of reality, common-sense, and a functional focus of interventions.sense, and a functional focus of interventions.

4.4. “All of us are smarter than any one of us.”“All of us are smarter than any one of us.”

Creating Alliances: Creating Alliances: Three Rules of Thumb for ProfessionalsThree Rules of Thumb for Professionals

1.1. Demonstrate respect all the time, especially when Demonstrate respect all the time, especially when interacting with someone that you don’t like (or interacting with someone that you don’t like (or who doesn’t like you!).who doesn’t like you!).

2.2. Seek the insights of everyday people - find the Seek the insights of everyday people - find the hidden experts and use their expertise.hidden experts and use their expertise.

3.3. Keep your hat in your hand; never forget you will Keep your hat in your hand; never forget you will always be a visitor in the life of the person with always be a visitor in the life of the person with whom you are working.whom you are working.

THAT’S WHAT I AM!

THAT’S WHO I AM!

RIGHT OR WRONG,I CAN’T CHANGE THAT

CARLITO (AL PACINO), CARLITO’S WAY

““I’ve lived a very dysfunctional life,I’ve lived a very dysfunctional life,and I know that that life has and I know that that life has shaped and molded me into shaped and molded me into

the person I am today.the person I am today.I want to reshape myself.”I want to reshape myself.”

- Lloyd K.- Lloyd K.

ChoiceChoice

(Noun)(Noun)

11 The act of choosing; selection The act of choosing; selection 22 the right, the right, power, or chance to choose; option power, or chance to choose; option 33 a a person or thing chosen person or thing chosen 44 the best or most the best or most preferable part preferable part 55 a variety from which to a variety from which to choose choose 66 a supply that is well chosen a supply that is well chosen 77 an an alternative alternative 88 purposive discernment. purposive discernment.

ImpulseImpulse

(Noun)(Noun)11 a)a) an impelling or driving forward with an impelling or driving forward with

sudden force sudden force b)b) an impelling force; an impelling force; sudden, driving force; push; thrust; sudden, driving force; push; thrust; impetus impetus 2 a)2 a) incitement to action arising incitement to action arising from a state of mind or external stimulus from a state of mind or external stimulus b)b) a sudden inclination to act, usually a sudden inclination to act, usually without premeditation without premeditation 33 sudden sudden involuntary inclination prompting action. involuntary inclination prompting action.

Functional Conceptions of Choice:Functional Conceptions of Choice:

••Free choiceFree choice

••Fixed choiceFixed choice

••Forced choiceForced choice

••Feeling the natural and logical results ofFeeling the natural and logical results ofactions in the environmentactions in the environment

For behavior-outcome linkages to serve For behavior-outcome linkages to serve as motivators, people must understand as motivators, people must understand

them, see them as relevant to their them, see them as relevant to their lives, and have the capabilities for lives, and have the capabilities for

utilizing them.utilizing them.- Edward Deci, 1995Edward Deci, 1995

Why We Do What We DoWhy We Do What We Do

In other words: People need to have In other words: People need to have both theboth the strategiesstrategies

and capacitiesand capacities for attaining desired outcomes! for attaining desired outcomes!

TheTheThree BigThree BigThingsThings

““When we think of your future – the next 10 years –When we think of your future – the next 10 years – we need to think about the 3 most importantwe need to think about the 3 most importantthings to work on; the things that, if you achieve, things to work on; the things that, if you achieve, you’ll have a meaningful life.”you’ll have a meaningful life.”

The 3 Things tend to cluster around these areas:The 3 Things tend to cluster around these areas:

••Behavioral regulation/self-regulationBehavioral regulation/self-regulation

••Friendships/social-interactionFriendships/social-interaction

••Vocational skills/meaningful engagementVocational skills/meaningful engagement

••Self-help skillsSelf-help skills

Being intrinsically motivated has to do Being intrinsically motivated has to do with being wholly involved in the with being wholly involved in the

activity itself and not with reaching a activity itself and not with reaching a goal.goal.

-Edward Deci, 1995-Edward Deci, 1995

Why We Do What We DoWhy We Do What We Do

Making the “Big Things” RealMaking the “Big Things” Real

Creating personal maps or steps to Creating personal maps or steps to attaining the personally meaningful attaining the personally meaningful goals.goals.

Articulated by the individual (with some Articulated by the individual (with some help from staff, friends, family)help from staff, friends, family)

Organized in a visual manner to assure Organized in a visual manner to assure clarityclarity

Step 1.Me Now

I’m good at:I need to:

Step 55.Me the:_______

I’m good at:I need to:

Step 2.

Step 3.

KEEPING A HOTTIE BOYFRIENDKEEPING A HOTTIE BOYFRIEND

IN THE RESOURCE ROOMIN THE RESOURCE ROOM

DEALING WITH PROBLEMSDEALING WITH PROBLEMS/BEING IN CONTROL/BEING IN CONTROL

LISTENING TO GOOD ADVICE/IGNORING BADLISTENING TO GOOD ADVICE/IGNORING BAD

HANDLING MYSELF IN CLASSESHANDLING MYSELF IN CLASSES

HANDLING MYSELF OUT OF CLASSESHANDLING MYSELF OUT OF CLASSES

BEING A GOOD PERSONBEING A GOOD PERSONWITHOUT THINKING ABOUT IT WITHOUT THINKING ABOUT IT

EULA’S STEPSEULA’S STEPSTO SUCCESSTO SUCCESS

HAVING A JOB, LIVING IN MY APARTMENTHAVING A JOB, LIVING IN MY APARTMENT

IN A TREATMENT PROGRAMIN A TREATMENT PROGRAM

MAKING MEETINGS & MAKING MEETINGS & PARTICIPATINGPARTICIPATING

IN THEMIN THEM

MAKING MY PLAN TO STAY CLEAN EVERYDAY MAKING MY PLAN TO STAY CLEAN EVERYDAY & LETTING PEOPLE KNOW& LETTING PEOPLE KNOW

DEALING WITH DEALING WITH ASSHOLES POSITIVELYASSHOLES POSITIVELY

MAKING PLANS BEFORE MAKING PLANS BEFORE GOING OUT IN THE WORLDGOING OUT IN THE WORLD

GET OUT OF IT BEFOREGET OUT OF IT BEFOREI GET INTO IT I GET INTO IT

PETER’S STEPSPETER’S STEPSTO SUCCESSTO SUCCESS

FOLLOW MY PLANFOLLOW MY PLANWHEN I’M OUT IN THEWHEN I’M OUT IN THE

WORLDWORLDPeople, Places, ThingsPeople, Places, Things

DON’T FORCE ITDON’T FORCE IT

In rehab

A doctor

An EMT

Be a helping person

Tom’s Plan & Tom’s Reality

More Intervention More Intervention Ideas:Ideas:

Conceptually Simple,Conceptually Simple,

Procedurally DifficultProcedurally Difficult

PERSON

MentalHealth

Cognition Language Emotion Volition Behavior

Human beings are a collection of Human beings are a collection of relatively independent structures, relatively independent structures,

processes, and systemsprocesses, and systems

John’s Cognition

Attention Perception Memory Organization Reasoning EF

ArousalSelectDirect/ FilterMaintainDivideShift

Encode/Store/RetrieveEpisodic/SemanticExplicit/ImplicitDeclarative/ProceduralInvoluntary/StrategicWorking Memory/ Knowledge BaseRemote/RecentPro/retrospectiveIconic

SequenceCategorizeAssociateAnalyzeSynthesize

InductiveDeductiveAnalogicalDivergentConvergent

Goals for John - John will:1. Increase duration of maintained attention2. Increase prospective memory from 3 to 5 minutes3. Increase category naming from 3 to 5 members per category

John’s Mental Health

Axis I Axis IIIAxis II Axis IV Axis V

Personality Disorders

Mental Retardation

GeneralMedical

Conditions

GlobalAssessment

of Functioning

Goals for John: John will1. Participate in psychotherapy sessions without falling asleep2. Comply with his medication regimen as directed3. Follow the recommendations of the clinical staff to assure his safety4. Seek community services for his disorder and for his living

arrangements

ClinicalDisorders

OtherConditions

PsychosocialAnd

EnvironmentalProblems

John’s Behavior

John

b1 b3 b12 b4 b1 b7 b62 b17 b17 b17 b4 b6 b9 b17 b12 b3 b8 b8 b5 b6 b17

Goals for John: John will1. Increase frequency of b3 and b122.Decrease frequency of b17

John is the totality of his behaviors and the systematic relationships among them

Alternative Understanding of Human Beings

Sarah

Pursuing personally meaningful goals

While participating in culturally valued activities

Using cultural tools, such as language, category schemes,mathematics, organizational supports, domain-specific strategies

Mediated as necessary by individuals with greater expertise in that domain

In social, cultural, and historicalcontexts

In the presence of varied context facilitators and barriers

GoalGoal

PlanPlan

DoDoReviewReview

PredictPredict

Constructing an identity Constructing an identity that is meaningful and that is meaningful and

sustainable is a primary sustainable is a primary goal of interventiongoal of intervention

“The self is not something ready made but something in

continuous formationthrough choice of action.”

- John Dewey

SENSE OF SELF FOR INDIVIDUALS WITH CO-SENSE OF SELF FOR INDIVIDUALS WITH CO-EXISTING DISABILITIESEXISTING DISABILITIES

PerplexityPerplexity Unawareness or denial: Retention of Unawareness or denial: Retention of

preinjury self-conceptpreinjury self-concept FragmentationFragmentation ““I am a victim” (passivity; depression)I am a victim” (passivity; depression) ““I refuse to be a victim” (anger; aggression)I refuse to be a victim” (anger; aggression) ““I’ve changed; I’ve got my work cut out for I’ve changed; I’ve got my work cut out for

me” (resolve)me” (resolve)

““IDENTITY MAPPING”IDENTITY MAPPING”

Identification of goalsIdentification of goals Identification of image, hero, metaphorIdentification of image, hero, metaphor Organization of identity descriptionOrganization of identity description [Creation of “identity map”][Creation of “identity map”] Supported practiceSupported practice Modification of others’ support behaviorModification of others’ support behavior Possibly meaningful projectPossibly meaningful project

An Identity Map

Reconstructing/Constructing IdentityReconstructing/Constructing Identity

POSITIVEIDENTITYMETAPHOR

FACTS

FEELINGS

APPEARANCE

GOALS PROCEDURES

What has thisperson done?

What does this person look like?

How does thisperson feel?

What will I need to do?

What am I trying to

accomplish?

IDENTITY CONSTRUCTIONIDENTITY CONSTRUCTION

Helping individuals with disability construct a Helping individuals with disability construct a sense of personal identity that is:sense of personal identity that is:

Satisfying/compellingSatisfying/compelling OrganizedOrganized Adequately realisticAdequately realistic

AND that includes the hard strategic effort AND that includes the hard strategic effort needed to be successful with a disabilityneeded to be successful with a disability

““IDENTITY MAPPING”IDENTITY MAPPING”

Identification of goalsIdentification of goals Identification of image, hero, metaphorIdentification of image, hero, metaphor Organization of identity descriptionOrganization of identity description [Creation of “identity map”][Creation of “identity map”] Supported practiceSupported practice Modification of others’ support Modification of others’ support

behaviorbehavior Possibly meaningful projectPossibly meaningful project

Identity Mapping: CautionsIdentity Mapping: Cautions

Professional competenceProfessional competence Emotional fragilityEmotional fragility Professional impositionProfessional imposition Cognitive prerequisitesCognitive prerequisites Meaningful languageMeaningful language

Identity Mapping: CautionsIdentity Mapping: Cautions

Dangerous metaphorsDangerous metaphors Negative use (e.g., “nagging”)Negative use (e.g., “nagging”) Getting stuck; flexibilityGetting stuck; flexibility Heroes and victimsHeroes and victims Time post injuryTime post injury

Goals:Simply comply

Others set goalsNo goals for self Feelings:

Anger at driver and all authoritiesInadequacy, dependenceHopelessness, frustration

Action strategies:No need for strategies; others take

responsibilityNo sense of responsibility

Other people’s charge

Appearance:Crutches, casts, etc

PeopleTherapists, physicians, aides

PlacesHospitals, clinics

Facts:TBI: 1991

Many injuries11 weeks: hospitalization

Casts, scars, crutchesMultiple surgeries Jason the

Victim

Goals:Freedom

IndependenceRetribution (driver, any

source of control)Victory!!!!

Feelings:Anger/Oppression

Power/ControlCompetence/Independence

Zeal for justice

Action strategies:When provoked, scorched earth policy

Demonstrate ability and powerDemonstrate others wrongExperiment with new thingsTry therapy (unsuccessful)

Appearance:Attempt to project power

PeopleEveryday people

PlacesEveryday places

Facts:Former marine

(Exaggerated) sense of Improvement

Disjointed life indisarray

Jason theMarine

Goals:First rate production

Make a clear statementDefine self

Feelings:Satisfaction

AccomplishmentGrowthControlFocus

Action strategies:Contemplate versus react

Plan for success (daily strategy formulation sessions;

daily plan sheets; barometer)Script in advance

Practice taking alternative perspectivesGoal-Plan-Do-ReviewUse supports wisely

Appearance:Appropriate to the context

PeopleSupport people

Non-conflict people

Places

Facts:Actor willing to be directed

DirectorMayor

ProducerSuccessful Clint

Eastwood

Reasons Why People Don’t Choose to Plan Reasons Why People Don’t Choose to Plan When They Could When They Could

Adapted from Ellis & Siegler, 1997

• • Planning requires delay in attaining goals andPlanning requires delay in attaining goals and the impulse for immediate gain is stronger thanthe impulse for immediate gain is stronger than the choice to delay an actionthe choice to delay an action

• • Planning requires the suppression of currently Planning requires the suppression of currently activated behaviorsactivated behaviors

• • Individuals are often overly optimistic about their Individuals are often overly optimistic about their success in the absence of planning, reducing the success in the absence of planning, reducing the perceived need for planningperceived need for planning

• • Planning takes time, and speed is often valued Planning takes time, and speed is often valued over accuracyover accuracy

A CommunityA Community

Shared purposeShared purpose Recognition of individual needsRecognition of individual needs

Ongoing articulationOngoing articulationof purposeof purpose

Identity(ies)/Roles/Identity(ies)/Roles/Places/JobsPlaces/Jobs

Procedures for managing Procedures for managing situations when participantssituations when participants

are out of rolesare out of roles

Shared ProjectsShared ProjectsProcedures for feedback fromProcedures for feedback from

community memberscommunity members

Community MeetingsCommunity Meetings

Staff Roles – Leader, supporterStaff Roles – Leader, supporterParticipant Roles – Leader, supporter, facilitatorParticipant Roles – Leader, supporter, facilitator

The Importance of Community in The Importance of Community in Establishing an IdentityEstablishing an Identity

Communities help us to accomplish things.Communities help us to accomplish things. Communities are change agents.Communities are change agents. Communities are sources of meaning and belonging.Communities are sources of meaning and belonging. Need to Belong Need to Belong (Baumeister & Leary, 1995)(Baumeister & Leary, 1995)

““The need to belong is a powerful, fundamental, and extremely The need to belong is a powerful, fundamental, and extremely pervasive motivation.” pervasive motivation.”

A lack of belongingness constitutes severe deprivation and A lack of belongingness constitutes severe deprivation and causes a variety of ill effectscauses a variety of ill effects. .

““Alone.... Uh, I’m alone! I'm a lonely, insignificant speck on a has-been planet orbited by a Alone.... Uh, I’m alone! I'm a lonely, insignificant speck on a has-been planet orbited by a cold, indifferent sun. “cold, indifferent sun. “ -Homer Simpson -Homer Simpson

The Belongingness Hypothesis: The Belongingness Hypothesis: A drive to form and maintain A drive to form and maintain at least a minimum number of lasting, positive, and at least a minimum number of lasting, positive, and significant interpersonal relationships.significant interpersonal relationships.

Social Identity TheorySocial Identity Theory People have an innate and strong tendency to mentally People have an innate and strong tendency to mentally

organize things and people into categories organize things and people into categories

To the extent that we associate ourselves with To the extent that we associate ourselves with communities (i.e. categorize ourselves), we have communities (i.e. categorize ourselves), we have social social identities identities

Social identities (via our community memberships) are Social identities (via our community memberships) are important aspects of how we define ourselvesimportant aspects of how we define ourselves

To the extent that we identify with communities that are To the extent that we identify with communities that are valued (e.g., powerful, prestigious, high status, popular), valued (e.g., powerful, prestigious, high status, popular), we’ll feel good about ourselves. we’ll feel good about ourselves.

ProjectsProjects Personally meaningful goal = Personally meaningful goal = productproductSENSE OF SELF AND MOTIVATIONAL THEMESSENSE OF SELF AND MOTIVATIONAL THEMES Expert role; helper/producer roleExpert role; helper/producer role Intrinsic motivation; meaningful engagementIntrinsic motivation; meaningful engagement Anti-egocentrismAnti-egocentrism Relevance, anti-oppositionalityRelevance, anti-oppositionality Awareness of strengths and needsAwareness of strengths and needsSOCIAL/BEHAVIORAL THEMESSOCIAL/BEHAVIORAL THEMES Meaningful context for practice of social/ interactive competenciesMeaningful context for practice of social/ interactive competencies Meaningful context for practice of collaborative, cooperative effort and Meaningful context for practice of collaborative, cooperative effort and

behavioral self-regulationbehavioral self-regulationCOGNITIVE THEMESCOGNITIVE THEMES Deep processingDeep processing Planning and organizingPlanning and organizing Meaningful context for practice of all cognitive and “Executive Meaningful context for practice of all cognitive and “Executive

Function” processesFunction” processes G-O-P-D-RG-O-P-D-R Compensatory strategiesCompensatory strategies

Integration of activity over time – day to dayIntegration of activity over time – day to day Integration of several contextsIntegration of several contexts

SELF REGULATION DEVELOPMENTThemesThemes

Start earlyStart early Develop slowlyDevelop slowly Continue into adulthoodContinue into adulthood Influenced by biologic and environmental Influenced by biologic and environmental

factorsfactors Variability: Context (person, setting and Variability: Context (person, setting and

task), motivation, culturetask), motivation, culture

SELF-REGULATORY DEVELOPMENT:SELF-REGULATORY DEVELOPMENT:The Role of ExperienceThe Role of Experience

Individuals are more likely to develop effective Individuals are more likely to develop effective self-regulation if they:self-regulation if they:

Experience adequate social attachmentExperience adequate social attachment Experience an organized and predictable worldExperience an organized and predictable world Receive “authoritative/apprenticeship” Receive “authoritative/apprenticeship”

parenting, including effective modeling and parenting, including effective modeling and verbal mediationverbal mediation

Are rewarded for appropriate self-regulation Are rewarded for appropriate self-regulation and control by others who value self-regulation and control by others who value self-regulation and autonomyand autonomy

Think out loud.Think out loud.

Think out loud a lot.Think out loud a lot.

Think out loud with the person: reflect, plan, problem solve, Think out loud with the person: reflect, plan, problem solve, observe, observe, organize, evaluate, remember, review, create, organize, evaluate, remember, review, create, etc.etc.

Make use of external supports when thinking: diagrams, photos, Make use of external supports when thinking: diagrams, photos, written written routines, day planners, notes, etc.routines, day planners, notes, etc.

Present yourself as an image of thoughtfulness. Help the Present yourself as an image of thoughtfulness. Help the individual to individual to embrace the notion that being thoughtful is a embrace the notion that being thoughtful is a good and great thing.good and great thing.

Think out loud in a way that shows that you are fun and Think out loud in a way that shows that you are fun and flexible and flexible and experimental in your own thoughts.experimental in your own thoughts.

Think out loud in a way that captures metaphors, analogies, Think out loud in a way that captures metaphors, analogies, similarities, similarities, history, etc.history, etc.

Teaching a Learning How to Think

WHAT WE’VE LEARNED WHAT WE’VE LEARNED OVER THE PAST 15 YEARS:OVER THE PAST 15 YEARS:

PRINCIPLES GUIDING THE DEVELOPMENT OF PRINCIPLES GUIDING THE DEVELOPMENT OF SUCCESSFUL SELF-REGULATION FOR INDIVIDUALS SUCCESSFUL SELF-REGULATION FOR INDIVIDUALS

WITH CO-OCCURRING DISABILITIESWITH CO-OCCURRING DISABILITIES

PRINCIPLE: ONGOING CONTEXT-PRINCIPLE: ONGOING CONTEXT-

SENSITIVE ASSESSMENTSENSITIVE ASSESSMENT Functional behavior assessmentFunctional behavior assessment Collaborative hypothesis testingCollaborative hypothesis testing Engagement of the person in the Engagement of the person in the

assessment processassessment process Assessment informs intervention/support Assessment informs intervention/support

informs assessment informs informs assessment informs intervention/supportintervention/support

Contextualized CollaborativeContextualized CollaborativeHypothesis-TestingHypothesis-Testing

What’s the problem?What’s the problem?(Using the two strangers in the doorway rule)

Hypothesis FormulationHypothesis Formulation(Why is s/he doing this?)

Hypothesis SelectionHypothesis Selection(Begin with easiest to test

or most obvious)

Hypothesis TestingHypothesis Testing(Protocol for experimentation

Plan A - Plan B - Plan CTesting time line)

WHY TEST HYPOTHESES?WHY TEST HYPOTHESES?

Failure on any complex task is Failure on any complex task is multiply interpretablemultiply interpretable

Complex students can be Complex students can be supported in a variety of wayssupported in a variety of ways

Test results do not necessarily Test results do not necessarily indicate how best to achieve indicate how best to achieve success on specific taskssuccess on specific tasks

WHY COLLABORATE?WHY COLLABORATE?

Increase observations and Increase observations and experimentsexperiments

Increase complianceIncrease compliance Educate family, staff, othersEducate family, staff, others EF training for studentEF training for student Show respectShow respect

WHY IN REAL CONTEXTS?WHY IN REAL CONTEXTS? InconsistencyInconsistency Validity problems of standardized Validity problems of standardized testingtesting

Impact of setting, person, activityImpact of setting, person, activity Impact of stressImpact of stress Observe real-world initiation, Observe real-world initiation, inhibition, self-monitoring, problem inhibition, self-monitoring, problem solvingsolving

Observe effects of real-world supports Observe effects of real-world supports and routinesand routines

Observe support behaviors of othersObserve support behaviors of others

PRINCIPLE: POSITIVE BEHAVIOR PRINCIPLE: POSITIVE BEHAVIOR

SUPPORTSSUPPORTS Environmental FocusEnvironmental Focus Antecedent FocusAntecedent Focus Logical and meaningful consequencesLogical and meaningful consequences Skill DevelopmentSkill Development

A B CTradition: Behavior is

a function of its consequences

A B C

Positive Behavior Support Alternative: Satisfying

behavior chains arecreated with everyday antecedent supports

Alternative Behavioral Paradigms

Success via Learning fromSuccess via Learning from ConsequencesConsequencesPresupposes:Presupposes:

Reasonable intactness of the neural Reasonable intactness of the neural networks responsible for connecting:networks responsible for connecting:

Memory for the factual aspects of past behaviorMemory for the factual aspects of past behavior

and/orand/or

Memory for the “Somatic Markers”, or the Memory for the “Somatic Markers”, or the feeling states associated with the consequences feeling states associated with the consequences of those behaviorsof those behaviors

Without these connections in memory, Without these connections in memory, past rewards and punishments past rewards and punishments

lack the power to drive future lack the power to drive future behaviorbehavior

ManageableRisk

ManageableRisk

LowRisk

BehaviorBehavior

Time

Fluctuations in behavior are expected, the goal of behavioral support is to make those

fluctuations manageable

High Risk/Unsafe/Unmanageable

High Risk/Unsafe/Unmanageable

ManageableRisk

ManageableRisk

LowRisk

BehaviorBehavior

Time

Fluctuations in behavior are expected, the goal of behavioral support is to make those

fluctuations manageable

High Risk/Unsafe/Unmanageable

High Risk/Unsafe/Unmanageable

PRINCIPLE: PRINCIPLE: THE PERSON IS THE CORE OF ALL THE PERSON IS THE CORE OF ALL

INTERVENTION AND SUPPORT EFFORTSINTERVENTION AND SUPPORT EFFORTS

Participation in goal setting and planningParticipation in goal setting and planning Case coordinationCase coordination Daily goal setting, planning, reviewingDaily goal setting, planning, reviewing

Participation in the assessment processParticipation in the assessment process Participation in selecting and managing staffParticipation in selecting and managing staff Which person?? Helping the person to create an Which person?? Helping the person to create an

identity that is:identity that is: Stable Stable PositivePositive Nondisability oriented Nondisability oriented But inclusive of hard strategic effortBut inclusive of hard strategic effort

Medical/ExpertModel:

I set your goalsI make your decisions

“Shallow”Person-Centered:“Whatever you

Say!!”

“Mature”Person-Centered:Organize supports

around goal-directed choices

Thesis:ExternalControl

Anti-thesis:Enable Impulsiveness

Synthesis:Facilitate goal-directed choice

Apparently irresolvableconflict

Goal-DirectedIdentity

Which Person??Which Person??“Person-Centered” Supports“Person-Centered” Supports

““Person-centered” does NOT mean never Person-centered” does NOT mean never having to say, “That’s not a good plan!! --- having to say, “That’s not a good plan!! --- That’s not a choice – that’s just impulse!!”That’s not a choice – that’s just impulse!!”

Administrative challenges:Administrative challenges: Who is authorized to help the person Who is authorized to help the person

distinguish between choice and impulse? distinguish between choice and impulse? Who facilitates goal-directed choosing and Who facilitates goal-directed choosing and

planning? planning? What are the scripts for other staff?What are the scripts for other staff?

Clinical challenge: Mature identity Clinical challenge: Mature identity construction construction

PRINCIPLE: INTERVENTIONS AND PRINCIPLE: INTERVENTIONS AND SUPPORTS ARE ORGANIZED SUPPORTS ARE ORGANIZED

AROUND PERSONALLY AROUND PERSONALLY MEANINGFUL ACTIVITIESMEANINGFUL ACTIVITIES

““In the absence of meaningful engagement In the absence of meaningful engagement in chosen life activities, all interventions in chosen life activities, all interventions will ultimately fail”will ultimately fail”

Option: School, work, volunteer Option: School, work, volunteer experiences, family responsibilitiesexperiences, family responsibilities

Option: Preparatory skill development Option: Preparatory skill development related to school, work, volunteer related to school, work, volunteer experiencesexperiences

Option: Meaningful projects!!Option: Meaningful projects!!

PRINCIPLE: POSITIVE EVERYDAY PRINCIPLE: POSITIVE EVERYDAY ROUTINES ARE THE CONTEXT FOR ROUTINES ARE THE CONTEXT FOR

PURSUIT OF MEANINGFUL GOALSPURSUIT OF MEANINGFUL GOALS Collaborative design of successful Collaborative design of successful

everyday routineseveryday routines Recognition of adherence to routines and Recognition of adherence to routines and

plansplans Ongoing reinforcement of planning, Ongoing reinforcement of planning,

routine development, and maintenance of routine development, and maintenance of positive routines: CELEBRATION of positive routines: CELEBRATION of everyday success!everyday success!

““Routine is despair’s sly assassin”Routine is despair’s sly assassin”

PRINCIPLE: FEEDBACK IS CONTEXT-PRINCIPLE: FEEDBACK IS CONTEXT-SENSITIVE AND MEANINGFULSENSITIVE AND MEANINGFUL

GOAL – OBSTACLE – PLAN – DO – REVIEWGOAL – OBSTACLE – PLAN – DO – REVIEW Celebration of effective maintenance of Celebration of effective maintenance of

positive everyday routinespositive everyday routines Celebration of special contributionsCelebration of special contributions Identification of what works and what doesn’t Identification of what works and what doesn’t

workwork Frank constructive feedback in response to Frank constructive feedback in response to

negative behavior delivered by a respected negative behavior delivered by a respected staff personstaff person

GoalGoal

PlanPlan

DoDoReviewReview

Obstacle/Obstacle/PredictPredict

PRINCIPLE: COMPONENTS OF LIFE PRINCIPLE: COMPONENTS OF LIFE

MUST BE INTEGRATEDMUST BE INTEGRATED People have an innate and strong tendency to mentally People have an innate and strong tendency to mentally

organize things and people into categories organize things and people into categories

To the extent that we associate ourselves with communities To the extent that we associate ourselves with communities (i.e. categorize ourselves), we have (i.e. categorize ourselves), we have social identities social identities

Social identities (via our community memberships) are Social identities (via our community memberships) are important aspects of how we define ourselvesimportant aspects of how we define ourselves

To the extent that we identify with communities that are To the extent that we identify with communities that are valued (e.g., powerful, prestigious, high status, popular), we’ll valued (e.g., powerful, prestigious, high status, popular), we’ll feel good about ourselves.feel good about ourselves.

A CommunityA Community

Shared purposeShared purpose Recognition of individual needsRecognition of individual needs

Ongoing articulationOngoing articulationof purposeof purpose

Identity(ies)/Roles/Identity(ies)/Roles/Places/JobsPlaces/Jobs

Procedures for managing Procedures for managing situations when participantssituations when participants

are out of rolesare out of roles

Shared ProjectsShared ProjectsProcedures for feedback fromProcedures for feedback from

community memberscommunity members

Community MeetingsCommunity Meetings

Staff Roles – Leader, supporterStaff Roles – Leader, supporterParticipant Roles – Leader, supporter, facilitatorParticipant Roles – Leader, supporter, facilitator

PRINCIPLE: BECAUSE THE DISABILITIES THAT FOLLOW PRINCIPLE: BECAUSE THE DISABILITIES THAT FOLLOW BRAIN INJURY ARE TYPICALLY CONTEXT-BOUND, BRAIN INJURY ARE TYPICALLY CONTEXT-BOUND,

CONTEXTUAL SUPPORTS ARE CRITICAL TO SUCCESSCONTEXTUAL SUPPORTS ARE CRITICAL TO SUCCESS Most critical to success:Most critical to success: Effectively trained “everyday people”Effectively trained “everyday people” Collaboration between:Collaboration between:

Clinicians and support staffClinicians and support staff Natural and paid supportsNatural and paid supports Participant and all supports: natural and paidParticipant and all supports: natural and paid

Elaborative supports: Elaborative supports: Designed to expand domain of activity beyond Designed to expand domain of activity beyond

disability supportsdisability supports Designed to improving thinking and decision makingDesigned to improving thinking and decision making

Feedback: authentic and context-sensitiveFeedback: authentic and context-sensitive

Components of Self-Coaching & Components of Self-Coaching & Self-Advocacy VideosSelf-Advocacy Videos

The negotiation and agreements that led to The negotiation and agreements that led to the play (or script or identity map) the play (or script or identity map) For those with faulty recollection of the rationale For those with faulty recollection of the rationale

for the play (or script or IM)for the play (or script or IM)

Educational content about the person’s Educational content about the person’s injury and its effectsinjury and its effects For the individual and Everyday PartnersFor the individual and Everyday Partners

Educational content about the social, Educational content about the social, vocational, or educational realities vocational, or educational realities surrounding the play (or script or IM)surrounding the play (or script or IM)

Review of self-coaching in everyday Review of self-coaching in everyday lifelife

At least weeklyAt least weekly Scripts “feel” ok??Scripts “feel” ok?? Meeting goals? Reducing problems?Meeting goals? Reducing problems? Celebrate everyday successes!!!Celebrate everyday successes!!! Never “failure” – if not working, try Never “failure” – if not working, try

something elsesomething else

Goal of Self-CoachingGoal of Self-CoachingGeneral goal:General goal: to improve planful goal- to improve planful goal-

oriented and ultimately successful oriented and ultimately successful behavior while decreasing impulsive and behavior while decreasing impulsive and reactive behaviorreactive behavior

Associated goalAssociated goal: to facilitate construction of : to facilitate construction of a positive sense of self based on effective a positive sense of self based on effective self-regulation/self-coaching and self-regulation/self-coaching and ultimately successful social and ultimately successful social and vocational participationvocational participation

Why Self-Observation on Video?Why Self-Observation on Video? Repetition/habituationRepetition/habituation

Context-sensitive automatizationContext-sensitive automatization Particularly for those with limited processing Particularly for those with limited processing

resources and weak on-line decision makingresources and weak on-line decision making Self-monitoring/self-awarenessSelf-monitoring/self-awareness Everyday communication partner self-Everyday communication partner self-

observationobservation Education:Education:

TBI informationTBI information Social informationSocial information OtherOther

Concreteness and immediacyConcreteness and immediacy

Self-Observation Cautions?Self-Observation Cautions? Serious emotional vulnerability may rule Serious emotional vulnerability may rule

out video self-observationout video self-observation Perception of self can be disturbingPerception of self can be disturbing Perceived image may be distortedPerceived image may be distorted Negative emotional states may be Negative emotional states may be

exacerbatedexacerbated Protocol: A relevant professional Protocol: A relevant professional

(psychologist, psychiatrist, social worker, (psychologist, psychiatrist, social worker, other trained counselor) needs to other trained counselor) needs to authorize video self-observation in cases authorize video self-observation in cases of emotional vulnerability.of emotional vulnerability.

Goals of Self-Coaching VideoGoals of Self-Coaching VideoVariableVariable Participant or ECP: Education about self-Participant or ECP: Education about self-

regulationregulation Participant or ECP: Education about TBIParticipant or ECP: Education about TBI Participant or ECP: Understanding of Participant or ECP: Understanding of

specific obstaclesspecific obstacles Participant: Rehearsal of self-regulatory Participant: Rehearsal of self-regulatory

or social scriptsor social scripts ECP: Negotiation and rehearsal of ECP: Negotiation and rehearsal of

acceptable cues or other scriptsacceptable cues or other scripts

PROCEDURESPROCEDURESOrigin of need for specific self-coaching Origin of need for specific self-coaching

scripts and videoscripts and video ParticipantParticipant Other participantsOther participants StaffStaff Family Family OtherOther

PROCEDURES PROCEDURES (CONT’D)(CONT’D)

Negotiation of self-talk script or social scriptNegotiation of self-talk script or social script With counselor individuallyWith counselor individually In counseling-oriented groupIn counseling-oriented group In self-coaching groupIn self-coaching group Collaborative process, with experienced Collaborative process, with experienced

group leader guiding the processgroup leader guiding the process

S-C Video: Possible ComponentsS-C Video: Possible Components Introduction to concept of self-coachingIntroduction to concept of self-coaching Introduction to the participant’s specific issue – ideally Introduction to the participant’s specific issue – ideally

with the participant and calling attention to the brain with the participant and calling attention to the brain injury-related issuesinjury-related issues

Possibly: brief vignette showing difficulty without use of Possibly: brief vignette showing difficulty without use of S-C scriptS-C script

Brief vignette showing success with S-C scriptBrief vignette showing success with S-C script With ECP or highly respected personWith ECP or highly respected person

Possibly: brief discussion of need for practice and what Possibly: brief discussion of need for practice and what will be evidence of successwill be evidence of success

Possibly “cheerleading” from peersPossibly “cheerleading” from peers

Some S-C “Plays” for EveryoneSome S-C “Plays” for Everyone The “Big deal/little deal” playThe “Big deal/little deal” play

Recognize/judge importance; block anxiety Recognize/judge importance; block anxiety The “Let’s think about that” playThe “Let’s think about that” play

Block impulsiveness; encourage thoughtfulnessBlock impulsiveness; encourage thoughtfulness The “New play” play (football: “audiblize”)The “New play” play (football: “audiblize”)

Encourage flexibilityEncourage flexibility The “Am I ready?” playThe “Am I ready?” play

Block impulsiveness; encourage readinessBlock impulsiveness; encourage readiness The “Am I sure?” playThe “Am I sure?” play The “What about you?” play The “What about you?” play

Block egocentrismBlock egocentrism The “Hang in there” playThe “Hang in there” play The “Goal-plan-do-review” playThe “Goal-plan-do-review” play

Encourage goal orientation and planfullnessEncourage goal orientation and planfullness

“The self is not something ready made but something in

continuous formationthrough choice of action.”

- John Dewey

Constructing an identity Constructing an identity that is meaningful and that is meaningful and

sustainable is a primary sustainable is a primary goal of interventiongoal of intervention

IDENTITY CONSTRUCTIONIDENTITY CONSTRUCTION

Helping individuals with disability construct a Helping individuals with disability construct a sense of personal identity that is:sense of personal identity that is:

Satisfying/compellingSatisfying/compelling OrganizedOrganized Adequately realisticAdequately realistic

AND that includes the hard strategic effort AND that includes the hard strategic effort needed to be successful with a disabilityneeded to be successful with a disability

““IDENTITY MAPPING”IDENTITY MAPPING”

Identification of goalsIdentification of goals Identification of image, hero, metaphorIdentification of image, hero, metaphor Organization of identity descriptionOrganization of identity description [Creation of “identity map”][Creation of “identity map”] Supported practiceSupported practice Modification of others’ support behaviorModification of others’ support behavior Possibly meaningful projectPossibly meaningful project

An Identity Map

Reconstructing/Constructing IdentityReconstructing/Constructing Identity

POSITIVEIDENTITYMETAPHOR

FACTS

FEELINGS

APPEARANCE

GOALS PROCEDURES

What has thisperson done?

What does this person look like?

How does thisperson feel?

What will I need to do?

What am I trying to

accomplish?

Know that an event or activity will be difficultKnow that an event or activity will be difficult

Establish reasonable goals (in some cases these might Establish reasonable goals (in some cases these might be immediate)be immediate)

Formulate a plan to achieve the goal (or understand the Formulate a plan to achieve the goal (or understand the plan)plan)

Initiate goal-directed behaviorInitiate goal-directed behavior

Refrain from actions that interfere with the successful Refrain from actions that interfere with the successful achievement of goalsachievement of goals

Attend to and evaluate how well they are doingAttend to and evaluate how well they are doing

Try another plan or strategy if things are not going wellTry another plan or strategy if things are not going well

To Assure Long Term Success To Assure Long Term Success Individuals Need to:Individuals Need to:

Think out loud.Think out loud.

Think out loud a lot.Think out loud a lot.

Think out loud with the person: reflect, plan, problem solve, Think out loud with the person: reflect, plan, problem solve, observe, observe, organize, evaluate, remember, review, create, organize, evaluate, remember, review, create, etc.etc.

Make use of external supports when thinking: diagrams, photos, Make use of external supports when thinking: diagrams, photos, written written routines, day planners, notes, etc.routines, day planners, notes, etc.

Present yourself as an image of thoughtfulness. Help the Present yourself as an image of thoughtfulness. Help the individual to individual to embrace the notion that being thoughtful is a embrace the notion that being thoughtful is a good and great thing.good and great thing.

Think out loud in a way that shows that you are fun and Think out loud in a way that shows that you are fun and flexible and flexible and experimental in your own thoughts.experimental in your own thoughts.

Think out loud in a way that captures metaphors, analogies, Think out loud in a way that captures metaphors, analogies, similarities, similarities, history, etc.history, etc.

Teaching Self-Regulation is Teaching People to Think

ROUTINESROUTINES• • Repetition creating temporal structure to improve memory Repetition creating temporal structure to improve memory about relevant past eventsabout relevant past events

• • Cognitive predictions about what happens nextCognitive predictions about what happens next

• • Natural occasions for promoting cognitive growthNatural occasions for promoting cognitive growth

• • An impetus for improvisation when trying to avoid An impetus for improvisation when trying to avoid a negative outcomea negative outcome

are a necessary prerequisite for

PlanningPlanning

ConcreteConcreteRoutinesRoutines

• • Picture RoutinesPicture Routines• • Written RoutinesWritten Routines

Interaction Interaction RoutinesRoutines

• • Language RoutinesLanguage Routines• • Activity SequencingActivity Sequencing

Routines to Deal with Changes in RoutinesRoutines to Deal with Changes in Routines

• • What I do when what I expected What I do when what I expected to happen doesn’t happento happen doesn’t happen

Key “Executive System”Concepts That Help Individuals

Learn Self-Regulation

Hard - Easy

Big Deal - Little Deal

Ready - Not Ready

Scary - Not Scary

Like - Don’t Like

Choice - No Choice

Interaction Scripts for RoutinesInteraction Scripts for Routines

Making Decisions Making Decisions About the GoalAbout the Goal

•• ““What’re you going to do?”What’re you going to do?”

•• ““What are we here for?”What are we here for?”

•• ““How will we know we’re done?”How will we know we’re done?”

•• ““We’ll know we’re done whenWe’ll know we’re done whenit looks like this . . . “it looks like this . . . “

Making PlansMaking Plans

•• ““OK, so what’s the plan?”OK, so what’s the plan?”

•• ““What’ll you need to get this done?”What’ll you need to get this done?”

•• ““How will you and I know you’ll How will you and I know you’ll need help?”need help?”

•• ““What will help look like?”What will help look like?”

• “• “Don’t tell me what you don’tDon’t tell me what you don’twant, tell me what you do want.”want, tell me what you do want.”

•• ““OK, so what do you want me to do?”OK, so what do you want me to do?”

Making Decisions About Ease orMaking Decisions About Ease or Difficulty Before BeginningDifficulty Before Beginning

• ““Do you think this will be hard or easy?”Do you think this will be hard or easy?”

•• ““If it’s hard, then what’ll you need?”If it’s hard, then what’ll you need?”

•• ““Have you ever done this before?Have you ever done this before?What happened?What happened?

•• ““I don’t think I could do this! How doI don’t think I could do this! How doyou know that you can?”you know that you can?”

•• ““Whaddaya think? Big deal or little deal?”Whaddaya think? Big deal or little deal?”

Coaching Through ProblemsCoaching Through Problems

•• ““You look upset, is there anything You look upset, is there anything I can do?”I can do?”

•• ““OK, you’re not ready. No problem;OK, you’re not ready. No problem;just let me know when you’re ready.just let me know when you’re ready.

•• ““I’ll know you’re ready when youI’ll know you’re ready when youlook like this . . .”look like this . . .”

•• ““I’ll wait.”I’ll wait.”

•• ““You know we’ve gotta figure thisYou know we’ve gotta figure thisout, let’s try . . . “out, let’s try . . . “

•• ““I know it’s hard, but we’ve got I know it’s hard, but we’ve got to do this.”to do this.”

Coaching in ContextCoaching in Context

•• ““So, how’s it going?”So, how’s it going?”

•• ““Is that helping you? Not helping?”Is that helping you? Not helping?”

•• ““Is there anything else you can do?”Is there anything else you can do?”

•• ““Is there anything I can do to help you?”Is there anything I can do to help you?”

•• ““So when are you going to start?”So when are you going to start?”

Review What OccurredReview What Occurred

•• ““So how’d it go?”So how’d it go?”

•• ““How’d you do?”How’d you do?”

•• ““Tell me exactly what happened . . .Tell me exactly what happened . . .and then what?”and then what?”

•• ““What do you think other peopleWhat do you think other peoplethought?”thought?”

•• ““What were you thinking when you . . .”What were you thinking when you . . .”

• “• “Next time you do this, what’ll you doNext time you do this, what’ll you dodifferently? The same?”differently? The same?”

•• ““What helped?What helped?

•• ““What didn’t help?”What didn’t help?”

PRINCIPLE: REDUCTION OF PRINCIPLE: REDUCTION OF

SUPPORTS IS PART OF THE PLANSUPPORTS IS PART OF THE PLAN Supports must be adjusted to fit needs and Supports must be adjusted to fit needs and

abilitiesabilities Systematic reduction of supports is Systematic reduction of supports is

planned from day 1planned from day 1 It is a goal of the waiver program to It is a goal of the waiver program to

empower people to succeed with natural empower people to succeed with natural supportssupports

BEHAVIOR

ExcessesImpulsivenessAggressivenessSubstance Abuse

DeficitsInitiation ImpairmentsInsight Impairments

COMMUNICATION

EfficiencyFluency/ArticulationDiscourse

EffectivenessFunctionalApparent

COGNITION

Organization Memory Info ProcessingPlanning Procedural vs. Declarative Non-strategicSelf Monitoring Implicit vs. ExplicitReviewingSelf-evaluating

Reasons Why People Don’t Choose to Reasons Why People Don’t Choose to Plan When They CouldPlan When They Could

• • Generating plans is no guarantee of success andGenerating plans is no guarantee of success andlack of past success influences the current choice to planlack of past success influences the current choice to plan

• • An Individual may believe that s/he has no control An Individual may believe that s/he has no control over outcomes, even if s/he does planover outcomes, even if s/he does plan

Planning is often unpleasant because it is difficult or Planning is often unpleasant because it is difficult or tedious or creates conflicttedious or creates conflict

• • An individual may assume someone else will make a plan An individual may assume someone else will make a plan for him/her for him/her

• • It’s often exciting NOT to planIt’s often exciting NOT to plan

Helping People Choose to PlanHelping People Choose to Plan

• • DO NOT plan on planning in situations that have DO NOT plan on planning in situations that have historical impulsive routines in placehistorical impulsive routines in place

• • Help individuals to “connect the dots”; make theHelp individuals to “connect the dots”; make the outcomes associated with planning explicit and outcomes associated with planning explicit and the likely outcomes associated with the likely outcomes associated with not not planningplanning equally explicitequally explicit

• • Show the positive effects of planning for the Show the positive effects of planning for the individual in the short term and long termindividual in the short term and long term

Helping People Choose to PlanHelping People Choose to Plan

• • Help the individual to make small/brief plansHelp the individual to make small/brief plans

with immediate outcomeswith immediate outcomes

Create a culture of planning early and oftenCreate a culture of planning early and often

Plan Plan withwith the person, the person, not fornot for the person the person

SR CHECKLISTSR CHECKLISTGENERAL CONSIDERATIONSGENERAL CONSIDERATIONS1.1. Is intervention in the areas that fall under the heading Is intervention in the areas that fall under the heading

"executive functions" structured around the individual's "executive functions" structured around the individual's own meaningful goals? own meaningful goals?

2.2. Is intervention infused into everyday activities? Are all Is intervention infused into everyday activities? Are all everyday people oriented to how they can facilitate everyday people oriented to how they can facilitate improved executive functions? Are all everyday people improved executive functions? Are all everyday people aware of the dangers of learned helplessness?aware of the dangers of learned helplessness?

3.3. Are everyday people aware of the strategies that the Are everyday people aware of the strategies that the individual is being taught or is expected to use?individual is being taught or is expected to use?

4.4. Is successful performance in the areas grouped under Is successful performance in the areas grouped under this heading richly and naturally rewarded? Is the this heading richly and naturally rewarded? Is the individual held responsible for effective strategic individual held responsible for effective strategic performance?performance?

5.5. Is the individual given ample opportunity to identify and Is the individual given ample opportunity to identify and solve his or her own problems (with guidance if solve his or her own problems (with guidance if necessary)?necessary)?

SR Checklist (cont’d)SR Checklist (cont’d)6.6. For individual's who are young or very concrete, are For individual's who are young or very concrete, are

executive function tasks structured around concrete executive function tasks structured around concrete physical activities (versus abstract or cognitive physical activities (versus abstract or cognitive activities)?activities)?

7.7. Do everyday people in the environment routinely Do everyday people in the environment routinely model expert use of executive functions?model expert use of executive functions?

8.8. Is the individual given sufficient practice so that Is the individual given sufficient practice so that strategic behavior becomes automatic?strategic behavior becomes automatic?

9.9. Are everyday people in the environment supportive Are everyday people in the environment supportive of strategic or compensatory ways to accomplish of strategic or compensatory ways to accomplish tasks?tasks?

10.10. Does the individual respect a strategic or Does the individual respect a strategic or compensatory approach to everyday problems? If compensatory approach to everyday problems? If not, is appropriate help/counseling provided?not, is appropriate help/counseling provided?

11.11. Are everyday people in the individual's environment Are everyday people in the individual's environment fully aware of possible limitations in the individual's fully aware of possible limitations in the individual's executive functions (esp., initiation and inhibition) so executive functions (esp., initiation and inhibition) so that they do not misinterpret behavior?that they do not misinterpret behavior?

Self-Awareness of Strengths and Self-Awareness of Strengths and NeedsNeeds

Is the individual maximally engaged in identifying Is the individual maximally engaged in identifying what is easy and hard to do, and what makes what is easy and hard to do, and what makes activities easy or hard?activities easy or hard?

Is the individual given opportunities to compare Is the individual given opportunities to compare performance when an activity is completed in a performance when an activity is completed in a usual way versus when it is completed with special usual way versus when it is completed with special strategic procedures?strategic procedures?

Does the individual keep a journal in which Does the individual keep a journal in which strengths and needs are recorded?strengths and needs are recorded?

Is the individual given opportunity to identify Is the individual given opportunity to identify strengths and needs in others, and strategic strengths and needs in others, and strategic procedures that others may use (e.g., peer procedures that others may use (e.g., peer teaching)?teaching)?

Is the individual given appropriate informative Is the individual given appropriate informative feedback (e.g., peer feedback, video feedback, feedback (e.g., peer feedback, video feedback, confrontational feedback if appropriate)?confrontational feedback if appropriate)?

Goal-SettingGoal-Setting Is the individual routinely asked to Is the individual routinely asked to

predict how well he will do on predict how well he will do on activities?activities?

Are predictions recorded in journals Are predictions recorded in journals and compared with actual and compared with actual performance?performance?

Does the individual maximally Does the individual maximally participate in rehabilitation/special participate in rehabilitation/special education goal setting? Is adequate education goal setting? Is adequate support provided if this is difficult?support provided if this is difficult?

Are intervention activities structured Are intervention activities structured around the individual's personal goals?around the individual's personal goals?

PlanningPlanning

Does the individual participate maximally in Does the individual participate maximally in planning his or her intervention activities?planning his or her intervention activities?

Is a planning guide available, if needed?Is a planning guide available, if needed? Does the individual begin the day by Does the individual begin the day by

preparing a plan on a planning board or in a preparing a plan on a planning board or in a journal? Does the individual begin each journal? Does the individual begin each activity by preparing a plan?activity by preparing a plan?

Do therapy activities include attempts to plan Do therapy activities include attempts to plan meaningful complex events (e.g., parties, meaningful complex events (e.g., parties, outings, etc.)?outings, etc.)?

Does the individual participate maximally in Does the individual participate maximally in long-term future planning? rehabilitation long-term future planning? rehabilitation planning? IEP development planning? IEP development

Self-InitiatingSelf-Initiating Do everyday people give the individual opportunities Do everyday people give the individual opportunities

to initiate and wait an appropriate length of time? to initiate and wait an appropriate length of time? Are signals available to remind the individual to Are signals available to remind the individual to initiate activities?initiate activities?

Do the activities that the individual engages in make Do the activities that the individual engages in make appropriate demands on the individual's ability to appropriate demands on the individual's ability to initiate (e.g., board games may require little initiate (e.g., board games may require little initiation; conversations may require much initiation; conversations may require much initiation)?initiation)?

Are all forms of institutional "learned helplessness" Are all forms of institutional "learned helplessness" avoided?avoided?

Are prosthetic initiators available if needed?Are prosthetic initiators available if needed? If initiation cues are necessary, are they provided as If initiation cues are necessary, are they provided as

much as possible by peers versus staff? Is nagging much as possible by peers versus staff? Is nagging avoided?avoided?

Self-InhibitingSelf-Inhibiting Do everyday people give the individual Do everyday people give the individual

opportunities to inhibit that are realistic in opportunities to inhibit that are realistic in their demands?their demands?

Do the activities that the individual engages Do the activities that the individual engages in make appropriate demands on the in make appropriate demands on the individual's ability to inhibit (e.g., individual's ability to inhibit (e.g., unstructured and unfamiliar activities in a unstructured and unfamiliar activities in a distracting environment require considerable distracting environment require considerable inhibition)?inhibition)?

If inhibition cues are necessary, are they as If inhibition cues are necessary, are they as subtle as possible and provided as much as subtle as possible and provided as much as possible by peers versus staff? Is nagging possible by peers versus staff? Is nagging avoided?avoided?

Self-Monitoring/EvaluatingSelf-Monitoring/Evaluating

Do everyday people give the individual Do everyday people give the individual opportunities to self-monitor and evaluate opportunities to self-monitor and evaluate performance? If cues are necessary, are they performance? If cues are necessary, are they subtle? Is nagging avoided?subtle? Is nagging avoided?

Is the individual maximally involved in Is the individual maximally involved in charting his own performance? keeping a charting his own performance? keeping a journal in which performance is recorded? journal in which performance is recorded? graphing performance? graphing performance?

Is the individual routinely asked to fill in a Is the individual routinely asked to fill in a form regarding his own performance: What form regarding his own performance: What Works? and What Doesn't Work?Works? and What Doesn't Work?

Intervention GoalsIntervention Goals

Sarah will successfully complete ___ Sarah will successfully complete ___ meaningful meaningful tasktask, with ___ , with ___ supportssupports, possibly using ___ , possibly using ___ “tools/strategies”,“tools/strategies”, in ___ in ___ contextcontext (setting, (setting, people, activities), in order to achieve ___ people, activities), in order to achieve ___ goalgoal..

Possibly focusing intervention attention on Possibly focusing intervention attention on some specific aspects of cognition, some specific aspects of cognition, communication, social skills, behavioral communication, social skills, behavioral self-regulation, or educational/vocational self-regulation, or educational/vocational skills – aspects that are either particularly skills – aspects that are either particularly weak or particularly important for Sarah.weak or particularly important for Sarah.

Teaching Positive AttributionTeaching Positive Attribution

UNHELPFUL ATTRIBUTIONUNHELPFUL ATTRIBUTION ““I can’t do anything well”I can’t do anything well” ““Teachers don’t like me”Teachers don’t like me” ““Other kids are lucky”Other kids are lucky” ““Sometimes I get it; sometimes I don’t; Sometimes I get it; sometimes I don’t;

I don’t know why”I don’t know why”

Teaching Positive AttributionTeaching Positive Attribution

HELPFUL ATTRIBUTIONHELPFUL ATTRIBUTION ““When I work hard and use my When I work hard and use my

strategies, I do OK; When I don’t, I do strategies, I do OK; When I don’t, I do badly”badly”

““Reading is harder for me than for Reading is harder for me than for other students, but I can get it if I give other students, but I can get it if I give myself enough time and use my myself enough time and use my strategies.”strategies.”

Teaching Positive Attribution: Teaching Positive Attribution: ProceduresProcedures

““Product Monitoring”Product Monitoring” FramingFraming Self-MonitoringSelf-Monitoring Hero IdentificationHero Identification Procedures associated with “learned Procedures associated with “learned

optimism”optimism”

EXPERIMENT ROUTINEEXPERIMENT ROUTINE“THIS WAY OR THAT?”“THIS WAY OR THAT?”

Identify issue or conflictIdentify issue or conflict Try both waysTry both ways Identify most successfulIdentify most successful General reassuranceGeneral reassurance

EF SCRIPTS:EF SCRIPTS:DELIVERYDELIVERY

Conversational, non-threatening interactionConversational, non-threatening interaction Well-selected languageWell-selected language Avoid boredom, irritationAvoid boredom, irritation Mainly positive: “easy” “non scary” “not a Mainly positive: “easy” “non scary” “not a

problem” “not a big deal”problem” “not a big deal” Massed and distributed practice (hundreds!!)Massed and distributed practice (hundreds!!) Embedded in meaningful activityEmbedded in meaningful activity Across all everyday partnersAcross all everyday partners

PROBLEM-SOLVING SCRIPTPROBLEM-SOLVING SCRIPT

Identify issue or conflictIdentify issue or conflict State the reasonState the reason Generate a solution/strategyGenerate a solution/strategy General reassuranceGeneral reassurance

HARD TO DO/EASY TO DO HARD TO DO/EASY TO DO SCRIPTSCRIPT

Identify task as hard or easyIdentify task as hard or easy State the reasonState the reason Generate a strategy (if hard)Generate a strategy (if hard) General reassuranceGeneral reassurance

BIG DEAL/LITTLE DEAL BIG DEAL/LITTLE DEAL SCRIPTSCRIPT

Identify the issue as a big deal or a little Identify the issue as a big deal or a little dealdeal

State the reasonState the reason Generate a strategy (if a big deal)Generate a strategy (if a big deal) General reassuranceGeneral reassurance

SCARY/NOT SCARY SCRIPTSCARY/NOT SCARY SCRIPT

Identify situation as scary or not scaryIdentify situation as scary or not scary State the reasonState the reason Generate a solution/strategyGenerate a solution/strategy General reassuranceGeneral reassurance

Problem Solving/Strategic Problem Solving/Strategic ThinkingThinking

Is the individual maximally involved in solving everyday problems Is the individual maximally involved in solving everyday problems as they arise? Are everyday people thoroughly oriented to the as they arise? Are everyday people thoroughly oriented to the importance of problem solving?importance of problem solving?

Is the individual maximally engaged in selecting strategies to Is the individual maximally engaged in selecting strategies to overcome obstacles and achieve important goals?overcome obstacles and achieve important goals?

Is there an appropriate amount of external support for strategic Is there an appropriate amount of external support for strategic thinking?thinking?

Does the individual have a form that cues the appropriate kind of Does the individual have a form that cues the appropriate kind of strategic thinking?strategic thinking?

Do everyday people in the environment expect and cue strategic Do everyday people in the environment expect and cue strategic performance?performance?

Do everyday people in the environment avoid learned Do everyday people in the environment avoid learned helplessness, that is, do they resist solving all of the individual's helplessness, that is, do they resist solving all of the individual's problems?problems?

Is there consistency among staff and family members in how Is there consistency among staff and family members in how problem-solving tasks are presented and in the kinds of external problem-solving tasks are presented and in the kinds of external problem-solving support that are provided? Is there consistency problem-solving support that are provided? Is there consistency in reducing external support as the individual becomes in reducing external support as the individual becomes increasingly independent in problem solving?increasingly independent in problem solving?

ROUTINESROUTINES• • Repetition creating temporal structure to improve memory Repetition creating temporal structure to improve memory about relevant past eventsabout relevant past events

• • Cognitive predictions about what happens nextCognitive predictions about what happens next

• • Natural occasions for promoting cognitive growthNatural occasions for promoting cognitive growth

• • An impetus for improvisation when trying to avoid An impetus for improvisation when trying to avoid a negative outcomea negative outcome

are a necessary prerequisite for

PlanningPlanning

Routine is despair’s sly Routine is despair’s sly assassin.assassin.

ConcreteConcreteRoutinesRoutines

• • Picture RoutinesPicture Routines• • Written RoutinesWritten Routines

Interaction Interaction RoutinesRoutines

• • Language RoutinesLanguage Routines• • Activity SequencingActivity Sequencing

Routines to Deal with Changes in RoutinesRoutines to Deal with Changes in Routines

• • What I do when what I expected What I do when what I expected to happen doesn’t happento happen doesn’t happen

““Much of our cognitive life may be the Much of our cognitive life may be the product of highly automated routines.”product of highly automated routines.”

- Gerald Edelman- Gerald Edelman

Steps to Organize Routines of Steps to Organize Routines of Everyday LifeEveryday Life

1.1.Identify successful and unsuccessful Identify successful and unsuccessful routinesroutinesof everyday life. What’s working, of everyday life. What’s working, what’s notwhat’s notworking?working?

2.2.Identify changes that have the Identify changes that have the potential topotential totransform unsuccessful routines intotransform unsuccessful routines intosuccessful routines (including successful routines (including changes in thechanges in theenvironment and the behaviors of environment and the behaviors of others.)others.)

3.3.Identify how changes in routines Identify how changes in routines includeincludeactivities that are motivating to the activities that are motivating to the individual individual and everyday people.and everyday people.

Steps to Organize Routines of Everyday LifeSteps to Organize Routines of Everyday Life

4.4. Implement needed supports to organizeImplement needed supports to organize

routines so that the individual experiencesroutines so that the individual experiences

success and receives intensive practice insuccess and receives intensive practice in

context.context.

5.5. Systematically withdraw supports and Systematically withdraw supports and

expand contexts as much as possible.expand contexts as much as possible.

GoalGoal

PlanPlan

DoDoReviewReview

PredictPredict

Key “Executive System”Concepts That Help Individuals

Learn Self-Regulation

Hard - Easy

Big Deal - Little Deal

Ready - Not Ready

Scary - Not Scary

Like - Don’t Like

Choice - No Choice

Interaction Scripts for RoutinesInteraction Scripts for Routines

Making Decisions Making Decisions About the GoalAbout the Goal

•• ““What’re you going to do?”What’re you going to do?”

•• ““What are we here for?”What are we here for?”

•• ““How will we know we’re done?”How will we know we’re done?”

•• ““We’ll know we’re done whenWe’ll know we’re done whenit looks like this . . . “it looks like this . . . “

Making PlansMaking Plans

•• ““OK, so what’s the plan?”OK, so what’s the plan?”

•• ““What’ll you need to get this done?”What’ll you need to get this done?”

•• ““How will you and I know you’ll How will you and I know you’ll need help?”need help?”

•• ““What will help look like?”What will help look like?”

• “• “Don’t tell me what you don’tDon’t tell me what you don’twant, tell me what you do want.”want, tell me what you do want.”

•• ““OK, so what do you want me to do?”OK, so what do you want me to do?”

Making Decisions About Ease orMaking Decisions About Ease or Difficulty Before BeginningDifficulty Before Beginning

• ““Do you think this will be hard or easy?”Do you think this will be hard or easy?”

•• ““If it’s hard, then what’ll you need?”If it’s hard, then what’ll you need?”

•• ““Have you ever done this before?Have you ever done this before?What happened?What happened?

•• ““I don’t think I could do this! How doI don’t think I could do this! How doyou know that you can?”you know that you can?”

•• ““Whaddaya think? Big deal or little deal?”Whaddaya think? Big deal or little deal?”

Coaching Through ProblemsCoaching Through Problems

•• ““You look upset, is there anything You look upset, is there anything I can do?”I can do?”

•• ““OK, you’re not ready. No problem;OK, you’re not ready. No problem;just let me know when you’re ready.just let me know when you’re ready.

•• ““I’ll know you’re ready when youI’ll know you’re ready when youlook like this . . .”look like this . . .”

•• ““I’ll wait.”I’ll wait.”

•• ““You know we’ve gotta figure thisYou know we’ve gotta figure thisout, let’s try . . . “out, let’s try . . . “

•• ““I know it’s hard, but we’ve got I know it’s hard, but we’ve got to do this.”to do this.”

Coaching in ContextCoaching in Context

•• ““So, how’s it going?”So, how’s it going?”

•• ““Is that helping you? Not helping?”Is that helping you? Not helping?”

•• ““Is there anything else you can do?”Is there anything else you can do?”

•• ““Is there anything I can do to help you?”Is there anything I can do to help you?”

•• ““So when are you going to start?”So when are you going to start?”

Review What OccurredReview What Occurred

•• ““So how’d it go?”So how’d it go?”

•• ““How’d you do?”How’d you do?”

•• ““Tell me exactly what happened . . .Tell me exactly what happened . . .and then what?”and then what?”

•• ““What do you think other peopleWhat do you think other peoplethought?”thought?”

•• ““What were you thinking when you . . .”What were you thinking when you . . .”

• “• “Next time you do this, what’ll you doNext time you do this, what’ll you dodifferently? The same?”differently? The same?”

•• ““What helped?What helped?

•• ““What didn’t help?”What didn’t help?”

An Important Goal of Intervention:An Important Goal of Intervention: Learning to Recognize Internal StatesLearning to Recognize Internal States

Using some commonly understood Using some commonly understood method of communicating “my” mood/method of communicating “my” mood/

feelings/health, etc.feelings/health, etc.

- Red – Yellow – Green- Red – Yellow – Green

- A thermometer- A thermometer

- Rating Scales- Rating Scales

I’m feeling really lousyI’m feeling really lousy

I’m feeling greatI’m feeling great

Recognizing and Communicating My Internal State Recognizing and Communicating My Internal State

Project Based InterventionProject Based Intervention

Present a project in terms of helping Present a project in terms of helping others identify important information for others identify important information for transitionstransitions

Provide a context to evaluate and plan for Provide a context to evaluate and plan for the “big picture” with Sarah and her familythe “big picture” with Sarah and her family

Provide a context to collaborate, as Provide a context to collaborate, as consultants, with the team (e.g., the aide, consultants, with the team (e.g., the aide, classroom teacher, vocational teacher, classroom teacher, vocational teacher, and parents).and parents).

Project Approach:Project Approach:RationaleRationale

Organizational impairmentOrganizational impairment Superior involuntary learningSuperior involuntary learning Weak elaborative encodingWeak elaborative encoding Need for situated learningNeed for situated learning Need for errorless learningNeed for errorless learning Need for routine learningNeed for routine learning

Project ApproachProject ApproachRationaleRationale (cont’d)(cont’d)

Internalization of mediated interactionInternalization of mediated interaction EgocentrismEgocentrism UnawarenessUnawareness Intrinsic motivationIntrinsic motivation OppositionalityOppositionality Sense of selfSense of self Self-esteemSelf-esteem

Project ApproachProject Approach

Meaningful goal; Meaningful goal; productproduct Deep processingDeep processing Planning and organizingPlanning and organizing Meaningful context for practiceMeaningful context for practice Integration of activity over timeIntegration of activity over time Integration of several contextsIntegration of several contexts Expert roleExpert role Helper/producer roleHelper/producer role

1 2 3 4 5 6 7 8 9 10

Cool Zone – Blue Zone Yellow Zone Red Zone

PeacefulDestructive

Past the Red Line

Red in the faceStaringLips clenched

Quiet Swearing

PERSEVERATION

Aaron’s Indicators:

Staff Scripts:

“Use your strategies” - take a break and move away - talk about what your feeling - listen to music

“Stop and breathe” “Clear the deck”- Get somewhere else quiet

Use the “Hard – Easy” Script-“Aaron is this hard or easy?”- “OK, if it’s hard, no problem I’ll give you some help.”

Use the Ready – Not Ready Script-“Aaron you’re not ready to do this.”-“I’ll know you’re ready when you look like ________.”

Following directionsMaking eye contact

AARON’S RATING SCALEPrior to, and following, each activity Aaron and his staff will evaluate his general mood using this scale. In addition, the scale can and should be used during activities as a way of helping Aaron recognize hismood changes, and the causes for those changes.

The Job:

Help people to learn to develop, and tell

THE STORYTHE STORY

Not simply report the news.

Four Lessons to Live by:

• Hope is an essential part of any successful plan of support.

• Form follows function. Think about what you need and

then create a way for that to happen in a flexible manner.

• The more you try to force something or someone to change,

the more it (or he or she) changes you.

• When all else fails, a sense of joy and a sense of humor

can get you through a whole lot!