I have heard many therapists share frustration over their client’s behaviors exhibited in therapy to the point that they question if their client is benefiting from services and as such contemplating discontinuing services until the learner’s behaviors improve.
I get it, it can be frustrating when we don’t feel equipped to handle challenging behaviors in our sessions. However, if you think about it, our clients with challenging behaviors often need us most. For example, if you consider behavior as a form of communication then it would make sense that the learner with a language delay needs to replace his problem behaviors with language.
Fortunately, there are few things that we as practitioners can do in our therapy sessions to establish and maintain learner cooperation to ensure the maximum benefit from our sessions.
Become a Conditioned Reinforcer
The first step is to pair with your client, or in other words build rapport. This is such an important step that can be easy or sometimes even challenging depending on the learner’s previous history of therapy.
I had a client that initially would tantrum when entering the building and would continue to cry when in my therapy room. His mother explained that he had a previous experience that resulted in him associating therapy, therapists and therapy spaces as an aversive experience. Needless to say, I had my work cut out for me!
But after a few sessions of placing minimal to no demands and rather simply playing and having fun he began to associate me, my toys, my treatment space and the building as a place where good things happened! Instead of crying at the sight of the building, he eagerly entered and began running to my treatment room ready to play. That was my sign that I, the treatment room and materials had shifted from being aversive to becoming reinforcers.
Ideally, you want to ensure that your client is able to tolerate your voice, your touch, your materials and your space as reinforcers. After all, it is your voice that will be delivering instructions, your touch which will be providing prompts and your materials that you will be using to teach. So, take as much time as you need at this step as it really is the most important step of all.
Build Trust
Once you have become a conditioned reinforcer, it is important that you not only build trust but also that you are able to maintain it. That means that you have to stay true to your word. If you say, “One more and then we can take a break,” by all means only do one more. I know firsthand how challenging this can be, especially if your client does well. If you are like me, your thought is to push for even more. Believe me, I have made that mistake many times and the result I got most of the time was a frustrated child.
Let the Learner Know What to Expect
We all thrive when we know what to expect. It is those times in our day when someone throws us a curve ball that we become stressed and at times even frustrated. Well, imagine a child being thrown a curve ball. Just as we use visuals such as reminders, daily schedules, to do lists, calendars, sticky notes, etc. to aid in our daily success our clients too can benefit from these strategies.
Using visuals such as a schedule can be a great tool to help your learner know what to expect in the therapy session. If a visual schedule is too much, simplifying by using a first/then board. This can be especially helpful when the task at hand is perhaps less preferred or more challenging as you can follow that task with something preferred (e.g., first “practice sounds” and then “play basketball”).
It can also be helpful for our clients to understand how many turns or how long a task is going to take, especially when it is something less preferred. Using visual timers or even token boards can be effective tools to let your client know how close they are to being done with the task at hand. After all, time can be an abstract concept for many of our clients.
Offer Choices
Let’s face it we all like to have a bit of control in our day, and our clients do too. A good way to offer this to our clients if to offer choices. Allowing them to choose the order of the tasks that you have laid out for the session is a good way to do this. You can also offer choices related to the reinforcers that they want to access, the number of times they want to say the their target sound (just be sure to offer a choice of the numbers you are aiming for), or the amount of time they are going to practice a given target.
Manage Reinforcement
Lastly, we cannot forget the power of reinforcement! We all have reinforcers that get us through the day. Whether it is a cup of coffee that gets us out of bed, or the excitement of spending time with a friend that we have not seen in a while, we all do what we do because of how it makes us feel.
Often times when I see a client engaging in challenging behaviors in a therapy session it is due to either a lack of reinforcement being provided, the wrong reinforcer being provided, or the amount of reinforcement being provided. For example, let’s say that your client typically loves bubbles, however the family of your client played bubbles right before session. Therefore, bubbles have lost their reinforcing effectiveness because they are in a state of satiation from playing with them prior to your session. It is important to communicate to families the value of not giving their child access to preferred items outside of therapy sessions. Additionally, just as our interests change, so do our clients which is why we should check in with our clients at the beginning of our sessions to see what they are interested in rather than just assuming that they are in to Play-Doh today because they liked it last session.
Finally, we must consider how much reinforcement to provide. For example, while you might jump at the challenge of $25 to run 1 mile, you likely would not accept a later challenge of $25 to run 5 miles. That is because the payoff needs to match the effort for the task at hand. So, if you blow bubbles after your client says their “f” sound correctly, you may want to reconsider blowing bubbles after they say “s” blends if “s” blends are harder and require more effort from your learner. The key to remember is that the harder the task the bigger the payoff should be. It is when demands become more challenging and reinforcement is too low that sets the stage to challenging behaviors.
When we create an environment that is fun, rewarding and allows our clients to have some control we can see some great things happen!
Feel free to reach out with any questions or to simply share your successes!