Therapist as a Coach in the Neuro Setting

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Answer

Dynamic coaching involves building collaborative relationships by explicitly instructing how to self-regulate in a variety of settings and for a variety of purposes. Self-regulation is the ability to assess, select, act, adapt, and understand how you yourself have input into each of these processes. Mary Kennedy did some work on coaching college students as they deal with executive function difficulties in a college setting. Many of the principles that she established translate into other settings as well (Kennedy, 2017). In Kennedy's college setting, she found that those with higher self-regulation abilities are more likely to graduate and have higher GPAs, compared to those students without effective self-regulation. That is not surprising, but it's always interesting when you do the actual study and it is true. Students with executive function disabilities lack these various self-regulation skills that would improve the likelihood of their success. They lack critical ways of thinking and problem-solving. Self-control and the ability to modulate oneself is vital for success in all domains of life. We're going to take these principles and expand them out to our brain injured population across the age span.

As a coach, your role is to express empathy. You're going to be empathetic to your patient's plight. You're going to develop discrepancy. Assess where you are now, and determine where you are headed (the current status versus the goal). Roll with resistance. In the brain injured population, we are going to be experiencing some resistance. At this point, it is advisable to avoid directly confronting your patient as much as possible. There's sometimes when we want to speak to them directly about what's going on, but in general, we're going to roll with the resistance so that we're not constantly arguing with our patient. You're not going to find a win/win arguing with your patient. Take the resistance and find ways to shape it into the performance that you need. We're going to support self-efficacy or the notion that your patient can achieve the goals that you've set, and indeed your patient wants to do that. We're promoting proficiency.

Four key components when dealing with self-regulation are:

1. Build a relationship
2. Model and facilitate self-regulation
3. Use natural learning and outcomes
4. Teach independent self-regulation 

Build a relationship. You need to know more about your patient than his Berg Balance Score and his gait speed. You have got to get into what his intrinsic motivators are. At one point in my own career, I switched from a boss who at acted like she cared about me as a person. She knew my children by name, she knew what activities they were involved in. Later in my career, I switched to a boss who just told me what I was doing wrong all the time. I was actually a top performer for this gentleman, but he neglected to find out why I do the work I do or what would motivate me to try even harder. As a coach, as a therapist, we absolutely have to figure out what drives our patients to want to succeed.

Model and facilitate self-regulation. We have to set goals and make a plan. For PT, look at what behaviors are causing your patient not to meet his goals. Are they not initiating completing their home program? If so, you're going to build goals and supports for achieving them. The goal could be that they need to stand for five minutes, five out of seven days. The starting point is zero days, then allow them to maybe begin with standing for three out of seven days. Set some alarms on their phone. Identify their helper at home. Set up a completion chart. Give them a phone call during the week. Home programs require a number of executive functions and functional behavior or self-regulation to complete. Providing a setting for success and some scaffolding for them to get there can lead to greater independence. As you know, if they're completing their home program, they're also going to get stronger. Supporting your patients through reaching mutually developed goals means using a communication style that is used to strengthen personal motivation for and a commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion. When we're talking about that relationship, it's mutual respect, but it's also incorporating the language of change within your relationship. You're helping to guide them into having the positive outlook that they can get to a place of change.

Use natural learning and outcomes. To achieve natural learning and outcomes, you want to use real-life situations to bring on the challenges. Utilize settings to allow for quick, routine decisions (e.g., which route should I take to get somewhere), as well as slow, more effortful ones (e.g., should I go to college). Context-based learning in a natural environment enhances the learning of new information. That is supported by research evidence. You must be able to self-evaluate the goal area to some degree to be able to participate in a dynamic coaching situation. For example, someone might be fully aware of their impulse control issue but have no awareness of their tendency to monopolize a conversation. They might not be ready to move into a dynamic coaching mode to address their pragmatic conversational skills, but we can look at their impulse control (Kennedy, 2017).

Teach self-regulation. When you're teaching self-regulation, you're going to look at all the potential goals you could select, and select the ones that are doable for the patient. Look at all those potential strategies that would conceivably work to address the goal, and then select the optimal ones and what your backup plan will be. Help them learn the strategy. Create steps and materials that help them get there. For your action plan, you're initiating the strategy steps, and you're tracking the strategy use. You're going to track their performance to see if they got to what they needed. Again, you can do that in the plan-do-review phase. Finally, you're going to compare their performance to their goal and adjust the goal and/or strategy to apply to other situations.

Kennedy, Mary (2017) Coaching College Students with Executive Function Problems.  The Guilford Press