Behaviour rehabilitation of the challenging client in less restrictive settings

Individuals who have sustained traumatic brain injury may provide friends, family, and rehabilitation professionals with challenges through an increased likelihood of their engaging in socially inappropriate behaviours. At extremes the inappropriate behaviours include vocal and physical assault, non-compliance, self-injurious behaviours, elopement, and property destruction. While these maladaptive behaviours are by themselves troublesome, for some individuals they provide severe barriers to rehabilitation. One option for the challenging rehabilitation client is a neurobehavioural programme, typically offering an access-limited or otherwise secure physical environment and which focuses on behaviour reduction. While outcomes from neurobehavioural programmes are typically positive, their expense and the negative connotations of this type of programme will at times dissuade family members from enrolling the client. We describe an alternative, less restrictive behavioural programme operated in the physical and social context of a larger, more typical community-based rehabilitation programme for traumatically brain-injured individuals. This programme has been in operation for nearly three years, successfully serving more than 200 clients, of which approximately 20% posed behaviour management problems. Identified variables accounting for these successes include: formal guidelines for programme development, staff training and monitoring, data collection, integration of an interdisciplinary team, discharge planning and post-discharge follow-up. We provide a general programme description followed by discussions of four brief case studies to illustrate basic principles of the programme. Programme strengths are discussed, as are constraints placed on the programme by the physical and social environments in which it operates.