Alternatives to extinction in brain injury rehabilitation. A reply to Wood and Thomas

In a number of important discussion papers, most recently in Brain Injury, Professor Wood and colleagues [1,2] have suggested that some authors [3–5], including ourselves, are reluctant to employ contingencies that may help clients inhibit disturbed behaviour after traumatic brain injury (TBI). They write that we prefer an approach that focuses more on helping patients recognize social and environmental antecedents as the main intervention to improve self-regulation, and that these approaches “lack a solid theoretical foundation” ([2], p. 203). We would like to take this opportunity to address what appears to be a misunderstanding of our position. In so doing, we seek to clarify further our views and to highlight the theoretical and empirical support for the interventions we do advocate.

It is the case that the authors of this letter probably do place a greater emphasis on the antecedents of aggressive behaviour than earlier neurobehavioural approaches [3,6]. We consider that taking account of antecedents and broader contextual factors will encourage staff to see beyond the person’s symptoms and to appreciate the importance of the individual’s goals, interests, values, and beliefs. Without a full understanding of the multiple factors that can influence aggressive behaviour staff are more likely to make unwarranted attributions related to client control and to adopt a negative bias, under-estimating the automaticity of emotion-driven responses [7,8].

Wood and Thomas [1] have identified the distinctive features of two types of sudden-onset aggression following TBI: impulsive vs episodic. Their description of impulsive aggression may be considered to have a significant overlap with the behavioural manifestations of hostile, ‘frustration-related’ aggression, which has been extensively studied [9–11]. The very term “impulsive” aggression implies that the behaviour is unplanned and reactive and, as such, may be less responsive to the manipulation of consequences, and more effectively managed via an alteration of antecedents. We suggest that repeated attempts to teach a person via consequences in such circumstances incurs the risk of actually strengthening the automaticity of aggression, as repeated links are made between the trigger and elicited aggressive behaviour (classical conditioning) [6]. Indeed, incidents of accelerating behavioural dysregulation have been reported following the application of extinction procedures in clients with severe TBI-related impairments [12,13].

We also consider that staff have a responsibility to intervene early in a behavioural cycle leading to aggression, which necessarily requires a greater emphasis on the study of antecedents. A recent study by Giles et al. [6] identified a large range of antecedent conditions that staff perceived as related to aggression in individuals with acquired brain injury in a low-demand treatment programme. Most of these antecedents were related to types of environmental irritants and could be modified by staff intervention and training, e.g. addressing interactional style, forewarning clients of aversive situations, normalizing and validating client experiences. The authors propose that aggression can be significantly reduced by lowering the readiness of individuals’ “fight/flight” responses and preventing the activation of automatic cognitions and motor sequences which prime aggression. In another study with a somewhat different client population, we have shown that the introduction of systemic client-centred interventions can reduce the incidents of aggression in a long-term care environment [14].

Like many clinicians using behavioural methods, our approach follows a general post-2000 trend in adopting a more positive, collaborative and person-centred approach with clients, with a focus on teaching adaptive social behaviours, serving the same communicative function as aggression [15]. This approach is beginning to accumulate an evidence base when used with clients with TBI [16–20]. The approach is more readily used in community settings and indeed, to date, only the Positive Behaviour Interventions and Supports (PBIS) approach of Ylvisaker et al. [5] has been evaluated in the community with clients with TBI [15]. The argument should not be one of either antecedents or consequences, but the sensible use of both antecedent management and manipulation of contingencies of reinforcement to achieve adaptive behaviour change. As Wood and Aldernam [2] have noted elsewhere, one of the authors of this letter has previously reported the use of extinction procedures to address very high levels of aggression in combination with positive approaches [13]. However, it is our view that extinction approaches ought to be avoided whenever possible, given their potential to confront or ignore the individual’s distress or anxiety [3,6]. Omitting such approaches is, we suspect, much more likely to lead to client engagement and satisfaction with treatment.