by Dr. Lisa Keliher
In 1985, I was on the floor, supporting people with mental health disorders, intellectual disabilities and developmental delays. By 1990, I was a graduate student seeking a master’s degree in counseling psychology.
I began my journey as a behaviorist as someone who invested her time, energy and focus on the betterment of others. I was required to complete a lot of paperwork which meant burning most of my scheduled hours. I used my off-hours to spend time with the clients and their teams. I quickly realized that observation informed my best work. Research related to co-morbidity should have informed best practices but it was either not available or useful in my early years. Evidence-based practices for adults with ID, ASD, mental health and medical issues were not at my fingertips.
In 1990, the awakening that adults with disabilities were complete human beings, more like the rest of the population than different, was just gaining formidable traction in society. In my corner of Maryland, no comorbid specialists were available to me. It was not uncommon that others would ask me how I successfully developed plans for short-and-long term change with so many variables to account for. The foundation of why I was successful is because I walked in my clients shoes.
In my first behaviorist position, I was responsible to teach 45 staff people what I was learning myself. When it came to people with multiple variables interfering with mood stability and learning capabilities; the client, the staff and I were on an island figuring it out. That’s not to say people didn’t offer their support and nice paper and pencil tracking sheets but those fell far short of the task I took on; how do I tap into these clients who are struggling?
How do I motivate staff to believe that, anytime and anywhere, anything can be taught and learned? Catch those good moments, celebrate them and set them up to happen again. Observe the client’s moment of struggle and breathe through it with them. See the client first as a person, second as a person expressing a behavior and third a person expressing a behavior that petitions thoughtful support.
How do I motivate client’s good choice-making? How much and what type of reinforcement does someone living with say, Intellectual disability, PTSD and chronic physical health issues require for that change? How much and what types of reinforcement does someone living with say, autism (ASD), depression and a seizure disorder require for that change? Do we need more on Monday after visiting with family and are stressed out? Do we need less when they just received a paycheck and are feeling “upbeat”?
What is the phase line necessary to motivate change while not reinforcing non-social behavior? Can the staff remain alert to the nuances of the client’s subtle attempts to make better choices?
In an upcoming blog, I will recall how much of my work with staff would have been significantly less laborious if they were Registered Behavior Technicians who were trained to work with adults; a skill set the RBT field is beginning to take seriously.
So how did I inspire an adult, with full rights to live her life as she pleased, to choose pro-social interaction styles? The preferences clients demonstrated were paired with behavior that allowed community integration and its related opportunities. Dislikes were met with options to escape. And I implemented that formula, individualized for each client, every day. The clients were heard.
My behavior plans were not stagnant in a binder, changes were informed by the client’s behavior. I fully embraced the times when a client declined an opportunity to earn a reinforcer as some of the best information I could be given. M&Ms weren’t always more effective than a glass of milk. The big-brother staff wasn’t always preferred over the neutral tempered staff. Classical music wasn’t necessarily stabilizing but rap music was.
The cookie cutter plans had no place in my work. It was necessary to give the client and staff tools and if a tool didn’t work, we never used punishment and we never forced. If someone took off their shirt in public – we placed blankets around her instead of forcing her to put on a shirt. If she allowed the blanket to remain held up in front of her, we rewarded (with a less preferred reinforcer) for the good choice of being more appropriate than 2 minutes earlier. Who can blame her for a hot flash, for an itchy tag, for wanting to leave the crowded park? She communicated and we acknowledged and set up the structure for the next time so success was more likely.
Once staff learned to celebrate the wins (communication) within the failures (taking off her shirt) the preconceived notions that “clients should just know (what to do)”, “clients can never learn (to be appropriate)” “what I know is more important than what they know” had less validity. Any staff person that implemented one of my plans knew that respect and humility drives the human relationship, no matter the level of cognitive or emotional functioning. Staff knew to explain every behavioral scenario via how they tried to walk in the client’s shoes, what that client may have needed (function) and how staff’s decision to intervene was made with full awareness and the best of intention.
Information exchange at the level of respect and humility led to the authentic development of effective interventions
In these early days of my behaviorist career, I silently asked for forgiveness to the client when one of my strategies failed to evoke change, but I simultaneously thanked the client because I knew him that much better. He taught the staff and the behaviorist how we missed something very important to him as a person. I learned because I listened to the data. What is the client telling me? My behavior plans morphed with every new failure and success and as a behaviorist, I morphed to be a better voice for my clients.
Awesome! I needed this ! Thanks Dr Lisa!