Disinhibition after Brain Injury – Tips and Strategies

Last week I talked about about disinhibition after brain injury; possible causes, and what you might see.

Today, still focussed on disinhibition, I have collected a list of strategies that might be helpful.

The tips and strategies below are grouped under a set of principles. Having a set of principles is like the foundation, or the pillars, upon which you can build good support.

Four reminders before you make any changes:

  1. Discuss strategies and ideas with the person you are supporting, their family and treating team, to decide what suits best.
  2. Start with strategies and changes the person is interested in.
  3. Try not to change too much, all at once.

Think B -E- C- A- U- S- E

BECAUSE is a set of principles that can help you build a list of actions to ensure you work successfully; with humanity and respect. They are the pillars that support and guide what you do.

Today I am applying these principles to supporting a person who has disinhibition after brain injury. You can add your own as you discover new ideas. Please share successful strategies in the Comments section below.

First the Principles:

BUILD for success – Positive and strengths based

EMPATHY – Put yourself in others’ shoes

COLLABORATE with the person, family and team

ATTITUDE – work in a way that respects and values the person

UNDERSTAND – learn as much as you can about the brain and brain injury, the person and their family (without prying), and your own role

STRUCTURE – be consistent in the way you work, develop routine and structure with the person

EASIEST CHANGES FIRST – change what is easiest to change – most likely to be environmental changes

 

The Principles in Action When a Person has Disinhibition After Brain Injury:

BUILD for success

  • Work on what the person CAN DO
  • Try and see the behaviour in another way for instance it can be refreshing to know exactly what someone is thinking.
  • Look at how you might train to regain or retain skills: think about Neuroplasticity
  • Give praise and positive feedback when things go well.
  • Discuss possible alternative, and acceptable, ways of responding.
  • Wherever you can find positive strategies to manage disinhibition. Work together on strategies that the person is comfortable with.
  • Review Cheryl Green’s blog post ‘Disinhibition and Meeting People After Brain Injury‘. Cheryl talks about her own experience and finding successful ways to manage the vulnerability that comes with disinhibition. She talks about making safer choices.

 

EMPATHY – Put yourself in others’ shoes

  • Take time to think about, and understand more about empathy and compassion.
  • Work to understand the impact of the cognitive changes and the impact on a person’s life. Think about how you might minimise or ideally overcome them.
  • Clearly explain to the person what you observe in a respectful way. Explain why it’s not OK and what would be a better response. “Liz when we go to the café for lunch you can not go past all the people waiting. You need to stand in the queue and wait your turn to get you lunch.”
  • If it is safe to do so, and not causing harm, it may be best to ignore the words or behaviour. You might talk about it later, or leave it alone.

 

COLLABORATE with the person, family and team

  • Listen and learn from the person and their family.
  • Discuss conversations or actions that were unsafe, or inappropriate and why. Jointly discuss what may have a been better response.
  • Together, work out visual cues that remind the person e.g. a“stop” hand signal, a short statement, or sometimes just a look might be enough.
  • Think about what works and what does not. What is helpful and what is not. Talk to the person, family and others involved to find the best strategies.

 

ATTITUDE – work in a way that respects and values the person

  • When finding your voice and way of supporting a person, make sure it is one of respect towards the person even when circumstances might seem out of control or absurd.
  • If you are in a situation where messages might be confused, such as assisting with personal care, or being in close proximity. Be respectful of both yourself and the person you are supporting. clearly explain what you are going to do and what response you expect. “I am going to put my arms around your body to help move you from the chair to the car, I need you to put your hands on the armrests to push yourself up”.
  • Where possible ensure situations are not open to misinterpretation – if you are a supporter outside of family and friends then think carefully about physical touch, being too familiar, or any behaviours on your part that might be misconstrued. Remember, even being in a person’s home helping prepare a meal could be misinterpreted.
  • If a person is confused at times, explain where they are, what they need to do and your role. Remembering this might need frequent reminders. “Hi Mr Z, its Jeannie. We are going to the bathroom now and I am going to help you have a shower”.

 

UNDERSTAND – learn as much as you can about the brain and brain injury, the person and their family (without prying), and your own role

  • Person first. Get to know the person don’t focus on the brain injury.
  • All behavior is a message!  Look at what message this behavior is communicating and how might that be addressed.
  • Remember it is not deliberate– the part of the brain that has the  “stop or pause button” has been damaged.
  • Think about the signals you might be giving as a supporter. Be clear and unambiguous.
  • You can play a role in helping others to understand why disinhibition after brain injury can happen.

 

STRUCTURE – be consistent in the way you work, develop routine and structure with the person

  • Try to respond consistently, and encourage others involved to do the same. It is helpful if everyone is responding in the same way and giving the same messages.
  • Learn about the range of strategies that form the foundation for supporting structure and consistency.
  • A structured, predictable routine can help minimize the stresses a person faces and therefore make it a little easier for them to manage cognitive challenges.

 

EASIEST CHANGES FIRST – change what is easiest to change – most likely to be environmental changes

  • It is often easier to change what is happening around the person than trying to change them. Carefully observe what is happening and what might trigger unsafe or inappropriate responses. What are the simplest, least disruptive changes that could make a difference. It might be something other people do, the way an activity happens, the timing, the situation or surroundings.
  • Move the person on to something else. Sometimes the best response is to move away from what is causing the person to react.  Jay is focussed on a person from another culture standing near him in a busy shopping centre, he is making racist comments in a loud voice. Annie looks around and sees a video game shop Jay loves, Annie suggests they visit the shop to move him away and change the subject.
  • It is often easier to avoid problems than to respond after the problem has escalated. If you know a situation, place, person or event triggers a response it might be better to avoid this while you put other strategies in place.

AND FINALLY

More information from a great resource about Brain Injury:

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