Martelli, M.F. (2000). A Behavioral Protocol for Increasing Initiation and Activity. Rehabilitation Psychology News, 27, 2, 12-13.
By Mike Martelli, Ph.D.
Concussion Care Centre of Virginia, Pinnacle Rehabilitation and Tree of Life
10120 West Broad Street, Suites G & H, Glenn Allen, Virginia 23060
Part 1: Task Analyses
Task Analysis involves breaking any task or chore or complex procedure into single, logically sequenced steps & recording the steps in a Checklist. The checklist allows checking off each step as it is completed. Task analyses always make task initiation, completion & follow through much easier. Performing a Task Analysis and generating a checklist can greatly improve ability to perform tasks in persons with limitations in memory, attention, energy, initiative, ability to sustain performance, organization, or almost any other difficulty.
Task Analysis Checklists are also extremely useful in minimizing fatigue by reducing the demand for, and energy consumed by reasoning and problem solving associated with planning, organizing & having to recall, make decisions & prioritize appropriate steps and sequences for a task. Task analyses are useful for both basic and complex behaviors. Most importantly, Task Analyses allow re-establishing the efficient routines that make up normal everyday human behavior and activity. When the procedures assisted by Task Analyses are repeated consistently, they eventually become automatic [habits] and become as natural as tying a shoe.
The ingredients for rebuilding these automatic habits are the 3 P's: Plan, Practice, Promotional Attitude (see additional handout). The result is rehabilitation, or removing obstacles to independence, and systematic achievement of incremental goals in desirable life areas.
Case Study #1:
Rehabilitation Loss of Initiative - Drive Following Anterior Communicating Artery Stroke
Background:
AT is 52yo high school principle who sustained an ACoA aneurysm that produced three week coma, inability to return to work. Premorbidly, AT worked 50 - 55 hours per week, and engaged in activities with children, yardwork, weekend activities, etc., and was reported to have a slightly above average activity level. He was seen 1.5 yrs post, about the time his wife was trying almost a last effort before divorce, because he wouldn't get out of bed most mornings before early afternoon, would return to bed after getting out and completing only one or two poorly executed grooming or washing tasks, and wouldn't shave, do nails, get haircut, etc. Patient complained of primary, pervasive lack of energy ("I got no get up and go...it's too hard...just let me sit/lay here a while...").
Intervention:
Amantadine was initiated, with only the slightest noticeable improvement. Psychostimulants produced side effects greater than energy / initiative increase.
A behavioral plan was initiated that included designing a Task Analysis (see below), represented as a poster check list. AT was cued by his wife, family, to follow steps, and showed almost immediate improvement with structured task analysis. Within three weeks, he was able to complete the routine without fail and even without referring to the check list, although he did initially require some supervision with getting out of bed to start the routine. Eventually, he was able to set and respond consistently to the alarm and independently initate and complete the routine. Concurrently, a continency management plan was adopted, involving patient rating difficulty of tasks preferred by wife, wife rating desirability of these, patient rating desirability of a few hard to identify motivating appetitive interest rewards (only a few could be identified at first: foot massage, home made chocolate cream pie, sex, etc; over a couple months, a list of approx. 20 was identified, with increased activity being associated with identifying new motivating rewards), wife rating difficulty of providing rewards, with results compiled into a simple multiplication calculation (i.e., desirability X difficulty on 1-10 rating scale) that produced points for performed activities that could be exchanged for appetitive desires.
Outcome:
Data are represented in a proliferation in number of activities, increasing from an average of about 10 per week pre-program (with requirement of considerable effort and cueing) to an agreed quota of 50 per week, usually with minimal cueing, after implementation. Patient become semi-autonomous with activity completion, needing only minimal supervision from wife most of time (e.g., ocassional calls, reminders about chores that could be completed), and more intense supervision, cues, phone call reminders, at other times. Every change in routine (e.g., holidays) produced regression and return for a booster treatment session, but the behavioral management strategies were mostly adopted by his family so reduced need for formal intervention was noted. Eventually, his family devised a contingency wherein patient could 'prime' his own pump by increasing activities back to quota to avoid having to visit psychologist (1 hour drive, and extremely fatiguing and unpleasnt trip)
Task Analysis Sample
AT's Initiative(Automatic Habit/Energy) Retrainer
MORNING
PURPOSE: Increase the frequency of highly desirable but infrequently occurring behaviors by rewarding their performance with highly desired outcomes or rewards.
METHOD: Identify highly reinforcing events and highly desirable behaviors and design a formal behavioral contingency program which allows exchange of points earned by performing desirable behaviors for highly rewarding events, as follows:
Rehabilitating Efficiency in Everyday Routine Following Traumatic Brain Injury.
Background:
Brain Injury Rehab Professional who sustained a complicated mild TBI with 8 hr. PTA and right parietal bleed that spontaneously resolved. Despite returning to work within one week to regular job, part time, and increasing to full time in one month, it was noted, after almost two years post injury, with adequate adaptation at work and no reported change from preinjury level of performance, that many ordinary daily routines were significantly less efficient, more time consuming, etc., with subsequent reduction in time for personal life. For example, taking more time to dress in am meant getting to work later, having to stay later, returning home in greater fatigue, reducing time available for desirable activities, etc. A task analysis was employed to identify employed tasks and sequences employed prior to injury.
Outcome:
Upon implementation, reinstitution of approximate premorbid level of everyday efficiency, as gauged by self reported estimate of time required to dress in am, maintain a relatively clean house, engage in social activities, pursue dating, etc. The list was employed for several weeks before storing away and only reviewing once or twice in the following year. Follow up one year later revealed that most, albeit not all, efficiency habits had been maintained (e.g., house cleaning habits were less consistently followed).
Single Doctor Chores CheatList (summary)
BATHROOM