Topic: Therapy - Setting Goals and Following Through

Question:

I am trying to help my wife, Marlene, with what are called "activities of daily living" following her brain injury several years ago. Her therapists have been trying to help her set priorities, and she is having difficulty with this. It seems that whatever she puts on her "To Do" list must get done, in her eyes. We are trying to slowly add household tasks to the list, but "slowly" is the operative word. If we agree in the morning that she will try to do the laundry sometime during the day, the next thing I know is that I come home and she has decided to clean all the closets too! Of course, that means the laundry is only half done and there is more work at the end of the day than either of us can handle. We both end up tired and frustrated. Have you seen this before, and what can I do to help?

Marvin in Texas

Dear Marvin,

Yes, I have seen this before. Many, many times! Not only have I experienced this type of problem personally, but virtually everyone I have worked with goes through a period where they struggle with setting priorities and following through on their top priorities.

Setting Priorities and Following Through
Setting priorities and following through with them is more complicated than it might appear. Prior to experiencing a brain injury, this rather complex mental process was handled within the brain relatively unconsciously. We were not aware that we set priorities, could remember them, would ferret out distractions during the day, and would/could follow through with executing our most important tasks. After a brain injury, things are different. We can still do the steps, but we often need to lay them out on paper in a way we can handle them. And it helps to be conscious of the steps and the fact that we need to lay things out in plain view. Also, keep in mind that setting priorities is different from the taking the steps to execute the most important tasks. This distinction is important!

Setting Priorities: Brainstorming
The first step is setting priorities in the first place. I'm curious, does Marlene actively participate in setting the priorities she agrees to do? She may be going through the motions, but end up feeling that they are not really her priorities. This is common when a person has difficulty setting their own priorities. To the helpers around them it seems like they lose either way. If they don't help the person set priorities in the first place, nothing gets accomplished. Yet, to the person being helped, if it's not their list of things to do and it feels like somebody else's list, they might not have the "ownership" of the list to be motivated enough to do the tasks on the list. Tough situation. My suggestion would be that you work with her on learning to brainstorm. Things to do. Ideas for places to go. Options for solving problems or making decisions. Can be anything. The important thing is that she gets practice brainstorming lists of things. Now, she will likely need some help with this because she may "go blank" on you at first. Those of us with brain injury benefit from learning how to visually cue ourselves -- sometimes by looking at old notebooks, sometimes by walking around the house asking ourselves pertinent questions, sometimes by asking others what they think. However you choose to help her with these lists, the key is for her to learn how to brainstorm lists to work from.

Setting Priorities: Coding "1", "3" "2"
The next step is to ask her to code the most important item on the list with the number "1". It's important to limit this to one item at first (coding the "top three" items is more difficult). Then, ask her to code the least important item with the number "3." Again, limit the selection to one item and don't ask her to go from items ranked "1" to items ranked "2." Best to go from "1" to "3" (the distinction is generally more clear). After she has ranked one "1" and one "3," then ask her to go back and select another "1," then another "3," Repeat this process until there are approximately equal numbers of 1's and 3's and some remaining uncoded items. The uncoded items will automatically become 2's. The process is the key to this strategy because it helps the person SEE that they actually do have priorities. The codes help them remember what they are (or retrieve their relative importance by looking on the paper, if their memory is too impaired to actually remember). Now, this exercise should be repeated many times -- many hundreds of time, perhaps. Through massed practice, a person will eventually re-learn to think in terms of priorities. It's also a process they can learn to apply to a variety of situations and problems. Do they want to decide what to buy? Do they want to make a decision about what to do to solve a problem? Do they want to figure out where to go to dinner? Coach them to apply what I call the "1-3-2" process to all these situations, and eventually they will have a resource for dealing with these kinds of things.

Following Through
Following through is a different process. And as you probably know by now, it's often difficult (or impossible) for someone with brain injury to accomplish multiple processes in a single step. Following through with either priorities or simple tasks requires several things. First, the person needs a strategy for scheduling the task, and secondly they need effective strategies for sticking with and executing it. In my experience, the most effective tool for the former is to become comfortable using a planner every day. This needs to become automatic (and so-called "automaticity" is a topic for another day). Learning to stick with a task and executing it may require other strategies, and learning to deal with distractions appears to be part of the problem. It sounds like Marlene started to do the laundry all right, but somewhere during the process she apparently noticed that a closet needed cleaning, so she got distracted with that and spaced whatever step she was on for doing the laundry. Then, since other closets needed cleaning too, she may have decided to work on them, as well. As time passed, she probably got immersed in the new tasks, spaced the original task and may have ended up totally overloaded and overwhelmed, right? Welcome home Marvin! There are a couple of strategies a person can learn to deal with this sort of thing.

FOCUS sheet
One is to use what I call a FOCUS sheet. It is propped up in large gold clip (these clips are sold in office supply stores for telephone messages). I have taught myself, and I teach my students, to write down what we want to focus on, on this FOCUS sheet (it's actually named, "FOCUS" sheet), and then place it somewhere it's visible to them throughout the day. I put mine in front of me in my work area. We then have a way to re-direct our attention if we get distracted (it's really a form of distracting ourselves with what we want to focus on). This focus sheet strategy also works well for things like "paying bills," "cleaning the bathroom" and a variety of other things.

STEPS card
Another strategy is to use what I call a STEPS card. This is a card for doing routine procedures, with all the steps laid out in plain view. If you want to see what the one I use looks like, it can be seen at: http://www.brainbook.com/lessons/STEPS/stpsblnk.jpg In a forum like this it's almost impossible to address all the issues that might be operating with setting priorities and following through with them. Suffice it to say that it's a complicated process, and there are many variables. But there are also solutions!

Family Support
You can also network with other family members who are likely dealing with the same kinds of issues. You can do this in local support groups, or even on the Internet. To find out what support groups might be available locally, contact your state Brain Injury Association. A list of them can be found at: http://www.biausa.org/States.htm This site has also put together a list of Internet-based e-mail support and discussion lists. Some are for families and others might be of interest to Marlene. A peer support list could help her learn strategies you have difficulty teaching her (sometimes it's easier to "hear" advice from a peer rather than a loved one or a therapist). The list of e-mail support lists can be found at: http://www.tbimo.org/groups.asp#internet

Hope this helps!

Kathy M.

University of Missouri - Columbia
School of Health Professions
Great Plains RCEP