For most rehabilitation patients, moving from the safety of a treatment center to the home environment can be an anxiety-provoking transition, regardless of whether the disability is temporary, progressive or age related. In counseling sessions with patients who have undergone these transitions, I have learned of the frustration that most patients feel. Patients have told me that they leave rehab centers with exercises and strategies to ameliorate symptoms, but often lack the behavioral life skills needed to re-establish their lives.

Rehabilitation education needs to equip patients not only with symptom-specific exercises and resources, but also with skills to help them problem-solve independently on a daily basis through real-life functional issues. This article will review a few basic principles of behavior therapy that you can integrate into sessions; patients can implement these techniques daily to regain their lives, step by step.

Identity-Behavior Links

At the most basic level, it is important to be mindful that for each individual, behaviors have feelings, memories and identities associated with them. In our society, we often measure people by what they are able to "do." When patients have to contend with changes in their functional status, whether losing function or learning compensatory strategies, a wide array of feelings often emerges as a result. Looking for ways for patients to continue to engage in behaviors that have personal meaning is an important initial behavioral intervention.

Jane, an 80-year-old woman with rheumatoid arthritis, shares what it was like for her to have a change in her ability to cook-an activity that had provided a lot of pleasure and identity for her:

"I love to cook. I also love cooking for my family. Every holiday was at my home. Once my condition progressed, I just realized that it was too stressful to go to the grocery store. I have my groceries delivered now. But, after talking to my OT, I realized I missed going to the market and picking out the vegetables myself. We talked about a solution. Now I go once a month, just for the fresh vegetables, and have the rest of my groceries delivered. I look forward to this trip every month."

Rating Skills (Energy Conservation)

All behaviors require both emotional and physical energy. Teaching patients how to rate their energy, both emotionally and physically, is critical in helping them to self manage their lives more effectively.

This can be accomplished by instructing patients to rate each task (on a scale of 1-10) for the perceived level of exertion-both physical and emotional. Since each patient has an individualized threshold for ADL and social activities due to his or her disability, the second part of this rating strategy asks patients to tune in to their own emotional and physical energy levels as they plan for the day.

The goal is to help patients develop an intuitive sense of how their own bodies work and match that sense to the amount of energy each task requires.

John, 34, an individual with relapse/remitting multiple sclerosis, explains how he learned to implement this behavioral skill in his own life:

"The hardest adjustment for me was that I could not be spontaneous anymore-meeting friends and going out for walks turns out to be an ordeal. Now I use rating skills to plan out my activities in ways that I can do it. Each day I decide what my energy level is and then I rate the energy required for the activities I plan to do that day, like shopping, taking a walk or studying. My counselor taught me to try to match my energy level with the things I want to do. I feel more in control now. I know my body is not the same. But doing things I could do before helps me to feel like myself again."

Behavioral Chains

Even for the most successful patient, managing disability or chronic illness is a constant challenge: dealing with setbacks, relapses and missteps. Teaching patients to analyze behavioral chains can also be helpful.

This strategy begins by identifying a behavioral target that a patient may want to change or modify. The client would look at the A-B-C's of a specific behavior, meaning that no behavior happens in isolation-there are links that happen before and after that continue the behavior.

The next step would be to ask the patient to self monitor the behavior (without judgment) to study how they get from Point A to Point C. The clinician and patient can then problem solve together on ways to increase or decrease behaviors.

Paul, 34, an automobile accident survivor who struggles with chronic pain, talked about how he utilized this skill:

"Since returning to my new job, I get easily stressed out, which throws me off with deadlines or getting back to people. People have been patient. But, I have been upset about not keeping up. My counselor and I looked at the ABC's of my day. I learned I needed to stretch out every two hours so I won't be in total spasms by the afternoon."

Behavioral Cues and Rewards

Instructing patients to set up behavioral cues can be a helpful strategy for adhering to consistent routines such as taking medications and doing exercises. Implementing self-care strategies is labor intensive for even the most resilient patient.

Jane provides example of how she uses this skill:

"Remembering everything I need to do and take is getting harder; I keep note cards in my rooms to remind myself of my routines and medication. I've learned I need to have back-up plans to my back-up plans."

Instructing patients to set up or identify behavioral rewards or reinforcers can be helpful with managing emotional burnout or maintaining motivation. When patients undergo functional changes, implementing functional strategies requires conscious effort. It is important to teach patients how to reward themselves and acknowledge even the smallest gains.

John shares how he was able to re-evaluate progress after back surgery:

"I used to jog-I always thought of myself as an able person. It felt discouraging to go from 'Wow, I ran six miles today,' to 'Wow, today I am only fatigued, not exhausted.' It took time to adjust to this new curve. But now, when I get through a week without exacerbating my back, I know that it's just as much of a big deal as running six miles. I schedule a massage each time I know I have dodged another episode."

Role Modeling

Finally, role modeling is an essential behavioral strategy. When patients undergo rehabilitation, they not only need to learn recovery/rehabilitation behaviors, but they also must re-learn functional behaviors to help them restore and re-envision new lives.

In behavior therapy, imitating and observing a model is a powerful way for an individual to adopt new behaviors. I highly recommend that clinicians distribute condition-specific articles, books or nformation on Web sites linking patients to stories about individuals who can serve as models of the possibilities of rehabilitation.

Lisa, a 36-year-old TBI survivor, shares an important perspective:

"I think I learned the most from other real people who struggle with disability. OTs and PTs only give you exercises to deal with your disability-but they don't tell you how to go on for the rest of your life with your disability. This is what I think patients really need help with. Three years ago, managing my symptoms filled up my day. I would feel very anxious and down all the time. I really learned how to problem solve from other disabled people. Now, my symptoms are in the background-I still have obstacles and hard days, but with my skills and watching how other people do it, I have a life again."

Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at rqm3463@nyu.edu.

Resources

The following reference can provide further information on behavioral strategies and techniques for clinicians to implement in sessions.