There are many and varied reactions which can arise in response to behavioural difficulties, the most extreme of which is punishment.
Following brain injury the person’s behaviour may at times be disruptive, frightening and distressing to others. This may include shouting, damaging property, violence, sexually inappropriate behaviour etc. If people without a brain injury behaved in this way, one would possibly consider using punishment to try to prevent recurrence of the behaviour (e.g. shouting at them, avoiding them, informing the police with a view to prosecution).
Those providing care and support to the person with brain injury person may understandably believe that punishment is justified as a response to challenging behaviour. If a person’s behaviour causes distress or harm to others then the normal view in our society is that they should be punished as a consequence. The evidence that punishment can bring about beneficial change in behaviour is actually weak. In fact, the use of effective reinforcement is a much more powerful means of bringing about positive behaviour change.
Relying on punishment to bring about behaviour change can actually create more problems than it solves. Some of the reasons for this are:
- Punishment can have a very negative impact on the person’s relationship with carers. Punishment damages all relationships including the therapeutic relationship.
- Punishment leads to major problems when it doesn’t work. The level of punishment can be increased, but where does this end? How extreme can punishments realistically be?
- Being ‘punished’ may result in the person engaging in ever more extreme behaviours. A ‘battle of wills’ may develop. If the person’s behaviour becomes more extreme, there is pressure for the severity of the punishments to increase in order to keep pace.
In the context of providing care and support to the person with brain injury, whatever the carer’s instinctive responses to challenging behaviour, it is most important that the approaches used are those most likely to bring about beneficial behavioural change i.e. reinforcement. It is also important to remember that the challenging behaviour arises as a direct result of the brain injury and its sequelae (see Causes of Behavioural Difficulties after Brain Injury).
It is important to remember that following brain injury all behaviour has a communicative purpose and needs to be understood in this context. Those providing care and support will benefit from professional, expert advice with regard to a comprehensive assessment and appropriate management of the behavioural difficulties.
As well as being inhumane, adopting a punitive approach could have serious medical and psychological consequences if the communicative purpose of the behaviour has not been recognised. It is always important to keep in mind the person may have difficulty expressing feelings of pain, low mood, frustration, anxiety, confusion or embarrassment etc. These experiences may therefore be expressed as challenging behaviour.