Acquired Brain Injury Case Study – an example of how SASBA can be utilised in clinical work (part 4)

First, BS’s behaviour needed to be understood in the context of his brain injury. It was recognised by the team that BS’s need for immediate gratification of his sexual needs, and reduced ability to suppress these, was ultimately a result of the organic changes arising from damage to his brain incurred as a result of falling. The most overt behavioural expression of these needs was TO: impairment of executive functions, especially his impulsivity, poor self-monitoring and lack of awareness further contributed to its presence and maintenance.

However, SASBA suggested other reasons as to why TO was evident. Most occurred during the afternoon when not attending rehabilitation sessions. Inspection of his therapy timetable showed that he had fewer sessions in his programme during that part of the day. BS was noted to enjoy social interaction, and this was readily available within therapy sessions; these facilitated structured activity which he usually enjoyed, and this occupation appeared to divert him from expressing his sexual needs. At other times, opportunities for social interaction were less readily available, which was further exacerbated as members of the MDT sought to avoid BS because of the distress inflicted on them through his behaviour.

As a consequence, and as Figure 4 shows, BS sought to express his needs by touching staff spontaneously, or take the opportunity to do so when MDT members were engaged with him in some other activity. Staff responded inconsistently when touched by BS. Some ignored or ‘played it down’ whilst others spoke to him. SASBA showed that this response was associated with the most severe TO. Discussion amongst the MDT revealed that because of the distressing nature of this behaviour, staff response was most typically a verbal reprimand. It was concluded by the MDT that despite admonishing BS, he was reinforced by the response his behaviour elicited to the extent that it was maintained and also encouraged. Furthermore, because this response from staff was not always available, its intermittent presentation served to motivate and reinforce his behaviour.

SASBA successfully demonstrated that whilst BS’s behaviour was primarily an expression of the organic damage incurred to his brain that was mediated by neuropsychological impairment, it was further shaped and maintained by the social environment within the rehabilitation unit.

The treatment plan

This understanding of what factors were maintaining TO elicited by SASBA was fundamental in helping the team to create an intervention to more effectively manage this behaviour. This consisted of multiple elements comprising the following:

1. 1)
   SASBA showed that most TO took place in the afternoon. Consequently, more opportunities for appropriate social interaction were made available to BS through the MDT by programming more therapy sessions throughout the day.
2. 2)
   Regular psychosocial education sessions were introduced, to help BS gain more awareness of the consequences of his behaviour, and to explore more appropriate ways of meeting his sexual needs.