BEHAVIOURAL FRAME OF REFERENCE

Historical Background

Development

The development of the Behavioral Frame of Reference can be traced back to the early 1900s with
the rise of behavioral psychology and behaviorism as a dominant approach within psychology.
Influenced by the works of B.F. Skinner, Ivan Pavlov, and John B. Watson, the field of occupational
therapy began incorporating behavioral principles into practice during the mid-20th century.

BEHAVIOUR

Behavior is defined by different authors in different ways, but generally it is considered to be an

observable and measurable reaction to internal or external events
Campbell et al. Behavior is anything a person does in response to internal or external events

Uher: Behavior is the interaction between individuals and their external changes or activities

Tinbergen: Behavior is the total movements made by an intact animal

Beck et al. Behavior is the externally visible activity of an animal that responds to changing
conditions

Starr and Taggart: Behavior is a response to external and internal stimuli that is integrated from
sensory, neural, endocrine, and effector components

Wallace et al. Behavior is the observable activity of an organism that involves action and/or response
to stimulation

Raven and Johnson: Behavior is the way an organism responds to stimulation

Davis: Behavior is what an animal does

Grier and Burk: Behavior is all observable or measurable muscular and secretory responses, and
related phenomena

MALADAPTIVE BEHAVIOUR

Bruininks, Woodcock, Weatherman, & Hill

Maladaptive behaviors are undesirable, socially unacceptable, or interfere with the acquisition of
desired skills or knowledge

VERBAL BEHAVIOUR

Psychologist B. F. Skinner defined verbal behavior as "behavior reinforced through the mediation of
other persons" in his 1957 book Verbal Behavior. Skinner's definition of verbal behavior emphasized
the function of language, or how it is used to interact and communicate with others, rather than the
meaning and structure of words

COVERT BEHAVIOUR
covert behavior refers to behavior such as thinking, imaging, and Understanding Applied Behavior
Analysis feeling that is not directly observable to the public.

COLLATERAL BEHAVIOUR

Collateral behaviors are behaviors that typically go together. The smiling and laughing of children
while eating candy or ice cream would be an example of collateral behavior.

CLASSIFICATION OF BEHAVIOUR IN CHILDREN

All behaviours in children can be divided into 2 categories:

1. Skill behaviour
2. Problem Behaviour

1. Skill Behaviour:
A positive, wanted, or adaptive human action that is sought to be taught for the benefit of
the learner.
Eg:
Motor- Runs, skips, jumps
ADL-Drinks from cup, eats with own hands, Undresses on own, etc
Language-Receptive language and expressive language
Reading and writing
Number and Time- Add single digit numbers, identifies numbers on clock, Count till 5, etc
Domestic and social: Namaste, please, thank you, hi
Prevocational and money: Using screw driver, recognise values of coins, etc
2. Problem behaviour:
A negative, unwanted, or maladaptive human action that causes stress on others, is either
harmful to self or others, is age inappropriate and interferes in the learning or teaching of
skill behaviors.
Eg:
Violent and destructive behavior
Temper tantrums
Misbehaviour with others
Self- injurious behaviours
Repetitive behaviours
Odd behaviours (Talks to self)
Hyperactivity
Rebellious behaviour
Anti-social behaviour
Fears

BEHAVIOURAL MODIFICATION
Behavior modification, sometimes referred to as “Behavior Mod,”has been defined as “the
application of experimentally derived laws of learning to human behavior” (Cautela 1970). Behavior
modification is the result of years of scientific research conducted in laboratories and in natural
settings, not just someone’s hunch or unproven theory.

What is it used to treat??

OCD

ADHD

Phobias

Generalised anxiety disoerder

Separation anxiety Disorder

THEORETICAL ASSUMPTIONS

1. Behaviour is predictable, measurable and objective

2. A person’s verbalisation and self- descriptions are behaviours
3. Patient has a repertoire of behaviour(adaptive and maladaptive) that have been learnt
throught selective reinforcement from the environment
4. Patient’s repertoire of behaviour determines his ability to function in activities of daily living,
work and leisure
5. Through positive and differential reinforcement and the systematic application of learning
techniques, the patient can learn to modify and control his behaviours
6. Only behaviours that is demonstrated can be reinforced
7. New behaviour maybe established through the use of continuous or frequent and
predictable reinforcement
8. If mal adaptive behaviour is only occasionally reinforced, it is strengthened
9. Strength of patient’s response is influenced by bodily conditions
10. A patient can learn new skills or refine present skills or learn to manipulate his environement
to solve problems and improve his functioning in his community
11. Therapist seeks to increase patients ability to transfer the behaviours learnt during treatment
to a broad range of appropriate situations
12. Skills for adaptive functions in natural environment are independent and non-stage specific
13. Clear concrete goals increase a patient’s understanding of focus of treatment which
expedited treatment process and facilitates evaluation of treatment outcomes.

ROOTS OF BEHAVIOURISM

Pavlov’s classical conditioning

Skinner’s operant conditioning
DIFFERENCTIAL REINFORCEMENT

Type Definition Example Goal

Differential Reinforce an appropriate

Reinforce a child for Replace inappropriate
Reinforcement of alternative behavior that
asking for help instead behavior with an
Alternative Behavior serves the same function as
of screaming. acceptable one.
(DRA) the problem behavior.

Decrease the
Praise a student for
Differential Reinforce the absence of a frequency of
refraining from yelling
Reinforcement of problem behavior within a undesired behavior by
during a 10-minute
Other Behavior (DRO) specified time interval. reinforcing its
interval.
absence.

Differential Reinforce a behavior that is

Reinforce sitting calmly Replace undesired
Reinforcement of physically incompatible
to reduce running or behavior with one that
Incompatible with the undesired
jumping. cannot co-occur.
Behavior (DRI) behavior.

Decrease the
Differential Reward a student for
Reinforce the behavior only frequency of a
Reinforcement of limiting interruptions to
when it occurs at or below behavior without
Low Rates of fewer than three times
a predetermined threshold. eliminating it
Behavior (DRL) in a class period.
completely.

Differential Reward a student for

Reinforce a behavior when Increase the frequency
Reinforcement of answering more than
it occurs at or above a of a desirable
High Rates of five questions during
specified rate. behavior.
Behavior (DRH) class discussions.
EXTINCTION

Extinction is a basic principle of behavior. The behavioral

definition of extinction is as follows:

Extinction occurs when

1. a behavior that has been previously reinforced

2. no longer results in the reinforcing consequences

3. and, therefore, the behavior stops occurring in

the future.

When a behavior is no longer reinforced, three things may

happen.

• The behavior may briefly increase in frequency, duration,

or intensity.

• Novel behaviors may occur.

• Emotional responses or aggressive behavior may occur.

SPONTANEOUS RECOVERY

The natural tendency for the behaviour to occur again in situations that are similar to those in which
it occurred and was reinforced before extinction

REINFORCEMENT TYPES

Reinforcement is anything that increased that a behaviour would recur - Skinner

Consumable reinforcers

Social reinforcers

Activity reinforcers

REINFORCEMENT SCHEDULES

Continuous reinforcement

Intermittent reinforcement

Fixed ratio

Fixed interval

Variable ratio

Variable interval
PUNISHMENT

Punishment occurs when a given behavior is followed by an adverse stimulus that cannot be escaped
or avoided.

Positive punishment is defined as follows.

1. The occurrence of a behavior

2. is followed by the presentation of an aversive stimulus,

3. and, as a result, the behavior is less likely to occur in

the future.

Negative punishment is defined as follows.

1. The occurrence of a behavior

2. is followed by the removal of a reinforcing stimulus,

3. and, as a result, the behavior is less likely to occur in

the future.

Time-out is defined as the loss of access to positive reinforcers for a brief period contingent on the
problem behavior

Response cost is the removal of a specified amount of a reinforcer contingent on the occurrence of a
problem behavior. Response cost is a negative punishment procedure when it results in a decrease in
the future probability of the problem behavior.

SHAPING

The process of shaping involves the system of giving rewards in a step by step fashion even to minor,
but correct approximations of behaviours towards a behavioural objective.
Getting Mrs. F to Walk Again

One case involved Mrs. F, a 75-year-old woman who had had hip replacement surgery. To walk
independently again, she needed physical therapy (PT). Specifically, she had to walk between two
parallel bars while supporting herself with her arms on the bars. However, Mrs. F refused to
participate in the PT. Because Mrs. F was not currently exhibiting the target behavior, O’Neill and
Gardner (1983) decided to use shaping. The target behavior was walking independently with her
walker. For a starting behavior, they wanted Mrs. F to go to the PT room where the parallel bars were
located. When Mrs. F arrived in the PT room in her wheelchair, the therapist interacted warmly with
her and gave her a massage treatment (a pleasant experience for Mrs. F). As a result, going to the PT
room was reinforced, and Mrs. F now went there willingly each day. After a few days, the therapist
asked Mrs. F to stand up between the parallel bars for 1 second (a successive approximation to
walking) before she could have her massage. Mrs. F stood up for 1 second and received her massage.
The therapist increased the duration to 15 seconds the next day, and Mrs. F stood at the parallel bars
for 15 seconds before receiving her massage (Figure 9-1). After Mrs. F was successfully standing
between the parallel bars, the therapist asked her to take a few steps one day and then a few more
another day, until she was walking the full length of the parallel bars. Eventually, Mrs. F was walking
independently with her walker and was discharged from the hospital. Because shaping involves
starting with a simple behavior that the person is already engaging in and building up to the target
behavior in small steps (successive approximations), the person can engage in a new target behavior
or a target behavior that they previously refused to do.

Steps:

Select the target behaviour

Select the initial behaviour that the child presenting perform and that resembles the target
behaviour in some way

Select powerful/ strong rewards

Reward the initial behaviour till it occurs frequently

Reward successive approximations of the target behaviour each

time they occur

Reward the target behaviour each time it occurs

Rewards the target behaviour now and then

Research on Shaping

Research shows that shaping has been used to generate a variety of

target behaviors in a variety of populations, including highlevel
athletic performance (e.g., Scott et al., 1997), therapeutic

exercise for headache control (Fitterling et al., 1988), toileting in

infants (Smeets, 1985), compliance with medical interventions by
individuals with intellectual disabilities (Hagopian &

Thompson, 1999; Rea & Williams, 2002; Slifer et al., 2002), academic engagement (Athens et al.,
2007), and children’s use of contact lenses (Mathews et al., 1992).
PROMPTING

Procedure of giving active assistance to help children to learn a specific target behaviour is called as
prompting

Types:

Physical

Verbal

Clueing

CHAINING

A sequence of steps required to perform a behavioural objective. The steps in the chain must be
classified by task analysis.

Forward chaining:When first step is taught first followed by later steps being taught last

Backward chaining: When last step is taught first

Guidelines for using chaining:

1. Describe each step in the chain that are to be followed so as to reach the target behaviour
2. Suppose a behavioural objective has been sequenced into five steps, initially begin teaching
by establishing a link between the first two steps alone. Then, proceed to link the first two
steps with third step. Still later, develop links between the first three and the fourth step
until, eventually, you reach the behavioural objective.
3. Use rewards to strengthen the behaviour at each step or link in the chain towards the
behavioural objective.
4. Preferable use backward chaining procedures when teaching self help skills to mentally
handicapped children
5. Always teach the child too perform the steps in the order in which they are listen in the chain
6. Move to the next step in the chain of behaviours only after the child has learned the
preceding steps in the link of behaviours towards the behavioural objective.
MODELLING AND IMITATION

A method of teaching by demonstration, wherein the teacher shows how a specific behaviour is to
be performed.

TOKEN ECONOMY

Tokens, which are tangible rewards given for appropriate behaviours and can be exchanged for
privileges.

The following are essential components of a token economy:

1. The desirable target behaviors to be strengthened

2. The tokens to be used as conditioned reinforcers

3. The backup reinforcers to be exchanged for the tokens

4. A reinforcement schedule for token delivery

5. The rate at which tokens are exchanged for the backup reinforcers

6. A time and place for exchanging tokens for backup reinforcers

FADING

Process of gradual decrease in the active assistance from teacher to wards active or independent
performance by the child when teaching specific behaviours is called as fading

GENERALISATION OF BEHAVIOUR

Process by which a behaviour learnt in a situation is transferred to be performed in another similar

situation is called as generalisation
STEPS INVOLVED IN BEHAVIOURAL MANAGEMENT PROGRAMME (BMP)

1. Identification of problem behaviour

2. Statement of problem behaviour
3. Selection of problem behaviour
4. Identification of rewards
5. Recording baseline of the problem behaviours
a. Baseline recording
i. Event recording: Record the number of times of a specific problem
behaviour occurs
ii. Duration recording: Record the duration of a given problem behviour in a
child
iii. Interval recording: Set apart specific interval of time in a period or day to
record whether the specific problem behaviour has occurred or not
6. Functional analysis of the problem behaviours
7. Development and implementation of behaviour management programme
8. Evaluation of behaviour management programme

ANALYSIS OF THESE FACTORS WILL HELP US TO UNDERSTAND AND MANAGE SEVERAL PROBLEM
BEHAVIOURS

1. Attention seeking factors

2. Self- stimulating factors
3. Skills deficit factors
4. Escape
5. Tangible factor

TECHNIQUES FOR MANAGING PROBLEM BEHAVIOUR

A. Changing the Antecedent
 Example: When the child is not engaged in any activity he tends to rocks his body.
Engage in an activity
B. Extinction/ ignoring
o Extinction: Removal of attention rewards permanently following a problem behavior
 Eg: Not talking to a child, not looking at the child
C. Time-out
 Removing the child from the reward or the rewards from the child from a particular
period of time following a problem behaviour
D. Physical restraint
 Physical restraint involves restricting the physical movements of the child for some
time following a problem behaviour.
E. Response cost
 Response cost is a behaviour modification technique that involves removing a valued
item or privilege after an undesirable behaviour occurs. It's also known as a
punishment procedure or penalty
 The goal of response cost is to:

i. Decrease the frequency of unwanted behaviours

ii. Teach individuals the concept of cause and effect

iii. Help individuals understand the consequences of their actions

F. Restitution (over correction)

Restitution in behaviours therapy is a disciplinary action or technique that helps people learn
to repair the harm they cause when they behave inappropriately
1. Restitution Overcorrection:
o The individual restores the environment to its original state and
improves it beyond the original condition.
o Example: A child who writes on the wall is required to clean the wall and
other walls in the room.
2. Positive Practice Overcorrection:
o The individual repeatedly performs the correct or appropriate behavior
as a corrective measure.
o Example: A student who mispronounces a word is asked to repeatedly
practice saying it correctly.

G. Conveying Displeasure
 we use of THIS technique, the teacher is required to give clear verbal
commands expressing displeasure to a child following occurrence of a
specific problem behaviour.
H. Graduated exposure for fears
I. Self-management techniques
 Self-observation
 Self-recording techniques
 Self-cueing techniques
 Self-reward techniques
 Correspondence training
  Anger control techniques

EVALUATION

Therapist has to identify the following :

1. Behaviours that contribute the adaptive functions

2. Behaviours that interfere the adaptive funtions
3. Behaviours necessary for adequate function in the patient’s natural environment
4. The frequency of specific adaptive and maladaptive behaviour
5. The stimuli that are acting as cues
6. The reinforcers for specific behaviours and when appropriate the person who supplies
reinforcement
7. The source of motivation for the patient’s behaviour
8. The ability of the patient to discriminate among stimuli and to generalise learning effectively
9. Priorities in treatment
Here are several complex scenarios to illustrate the application of the Behavioral Frame of
Reference in different contexts, each with unique challenges and multiple layers of intervention:

1. Pediatric Therapy: Sensory Overload and Behavioral Outbursts

Context: A 5-year-old child with autism exhibits self-injurious behaviors (head-banging) when
overwhelmed by sensory input during school activities.

 Intervention:

o Antecedent Control: Create a sensory diet with scheduled breaks and calming
activities to prevent overload.

o Positive Reinforcement: Use a token economy system to reward calm behavior

during overstimulating situations.

o Replacement Behavior: Teach and reinforce alternative behaviors like using a "quiet
corner" or wearing noise-canceling headphones.

 Challenges: The child initially resists using replacement behaviors, requiring shaping and
modeling.

2. Adult Mental Health: Work Reintegration

Context: A 35-year-old client with generalized anxiety disorder struggles to rejoin the workforce due
to avoidance behaviors triggered by fear of failure.

 Intervention:

o Graded Exposure: Gradually introduce work-related tasks, starting with simple

home-based assignments and moving to short work hours.

o Behavioral Contracting: Develop a written agreement outlining goals,

reinforcements (e.g., earning privileges), and consequences for avoidance.

o Reinforcement: Offer verbal praise and tangible rewards for each successful step
completed without avoidance.

 Challenges: The client frequently backslides into avoidance, requiring re-negotiation of task
difficulty and reinforcement schedules.

3. Geriatric Rehabilitation: Cognitive Decline and Wandering

Context: An 80-year-old patient with dementia frequently wanders away from the care facility,
endangering themselves and causing staff distress.

 Intervention:

o Antecedent Control: Use visual cues (e.g., STOP signs on doors) and environmental
modifications to reduce wandering triggers.
 o Differential Reinforcement: Reward the patient for engaging in preferred, safe
activities like walking in a monitored garden.

o Replacement Behavior: Introduce structured physical activity programs to fulfill the

patient’s need for movement.

 Challenges: Consistency across caregivers is difficult to achieve, leading to intermittent

reinforcement of wandering.

4. Pediatric Rehabilitation: Poor Compliance in Therapy

Context: A 10-year-old recovering from a traumatic brain injury (TBI) refuses to engage in physical
therapy sessions due to fear of pain.

 Intervention:

o Shaping: Start with minimal physical effort tasks and gradually increase difficulty as
confidence builds.

o Reinforcement: Implement a reward system where the child earns points for each
task completed, redeemable for a favorite activity.

o Modeling and Role Play: Show videos or involve peers demonstrating successful
participation in therapy.

 Challenges: Emotional breakdowns require the therapist to de-escalate and reintroduce

tasks later.

5. Stroke Rehabilitation: Family Conflict

Context: A stroke survivor, Mr. Kumar (60), struggles to follow his therapy routine at home due to
family members unintentionally reinforcing his dependency by doing tasks for him.

 Intervention:

o Behavioral Contracting: Collaborate with the family to set clear rules about
supporting Mr. Kumar only when needed.

o Reinforcement for Independence: Provide positive feedback whenever Mr. Kumar

completes tasks independently, such as dressing himself.

o Education for Caregivers: Train family members on how to avoid reinforcing

dependency and instead encourage self-reliance.

 Challenges: Family resistance to change requires motivational interviewing techniques.

6. Chronic Pain Management: Avoidance of Movement

Context: A client with chronic back pain avoids physical activity due to fear of exacerbating their
pain, leading to deconditioning.
  Intervention:

o Graded Activity: Introduce a "pacing" strategy to perform small, manageable

activities without exceeding pain thresholds.

o Positive Reinforcement: Praise and reward engagement in physical activities, even if

minimal.

o Cognitive Reframing: Pair behavioral strategies with education to challenge the

belief that all movement causes harm.

 Challenges: The client shows resistance to increasing activity levels, requiring consistent
encouragement.

7. Substance Abuse Recovery: Addressing Relapse Triggers

Context: A 28-year-old client in recovery from substance abuse relapses when exposed to specific
social environments.

 Intervention:

o Antecedent Management: Identify and avoid high-risk environments while

developing new social routines.

o Behavioral Substitution: Reinforce healthy alternatives, such as exercise or hobbies,

when the client feels triggered.

o Reinforcement Schedules: Use immediate rewards for maintaining sobriety in

challenging situations.

 Challenges: Peer pressure requires the therapist to work on assertiveness training and
coping mechanisms.

8. Post-Traumatic Growth in NICU Mothers

Context: A mother of a premature infant in the NICU shows signs of post-traumatic stress and
refuses to engage in parenting routines, fearing harm to the baby.

 Intervention:

o Behavioral Activation: Gradually involve the mother in low-stakes caregiving tasks

like holding or feeding under supervision.

o Reinforcement: Use verbal affirmations and photo diaries to show her progress and
strengthen her self-efficacy.

o Psychoeducation: Pair with education about the baby’s resilience to reduce fear-
driven avoidance.

 Challenges: High emotional distress can lead to intermittent withdrawal, requiring a patient
and empathetic approach.
9. Intellectual Disability: Self-Injurious Behavior

Context: A 15-year-old with moderate intellectual disability engages in self-harm (e.g., biting) when
frustrated with communication challenges.

 Intervention:

o Functional Behavior Analysis: Identify triggers and develop a communication system

(e.g., picture exchange).

o Differential Reinforcement of Alternative Behavior (DRA): Reinforce the use of

communication aids instead of self-harming behaviors.

o Shaping: Gradually expand the communication repertoire and reward each new
attempt.

 Challenges: Frequent frustrations may lead to relapses that require consistent redirection.

10. Adolescent Social Skills Group

Context: A 14-year-old with social anxiety avoids participating in group therapy sessions and remains
silent when asked to speak.

 Intervention:

o Modeling and Role Play: Demonstrate effective social interactions and practice with
peers in a low-pressure setting.

o Graded Exposure: Gradually increase the level of participation, starting with

observing, then small group discussions, and eventually presenting ideas.

o Positive Reinforcement: Use verbal praise and social rewards (e.g., peer recognition)
to encourage participation.

 Challenges: Emotional shutdowns during sessions require immediate re-assurance and

adaptation.

These examples cover a range of populations and settings, showcasing how the Behavioral Frame of
Reference can be adapted to address complex challenges. Each scenario emphasizes individualized
interventions and the dynamic nature of behavioral therapy.

1. Severe Behavioral Outbursts in a Child with Autism

Scenario:
A 7-year-old child with autism exhibits severe tantrums, including screaming, hitting, and throwing
objects, whenever their preferred activity (tablet time) is interrupted.

Activity Setup:

 Participants: Therapist, parent, and child (acted by a therapist or volunteer).

 Role Play Structure:

 o Simulate an environment where the child is using the tablet, and the parent
announces "5 more minutes" before taking it away.

o When the child reacts negatively, the therapist demonstrates a structured approach:

 Use of a visual timer to prepare the child.

 Offering a preferred activity as a transition (e.g., sensory play).

o Practice with the parent taking the lead while the therapist provides feedback.

Behavioral Goals:

 Teach parents to use antecedent control (e.g., visual schedules).

 Replace maladaptive behaviors with functional communication (e.g., asking for more time or
help).

Challenges:

 The child may escalate behavior despite interventions. Parents are guided to use extinction
(ignoring tantrums) paired with immediate reinforcement of appropriate behaviors like using
words or gestures.

2. Substance Abuse Recovery: High-Risk Situations

Scenario:
A 30-year-old recovering from alcohol dependence struggles with relapse when visiting friends who
drink socially. Peer pressure and fear of rejection drive their behavior.

Activity Setup:

 Participants: Client, therapist, and role-playing peers.

 Role Play Structure:

o Simulate a social gathering where peers offer drinks.

o Teach assertiveness techniques:

 Practice scripts like, "No thanks, I'm good with water," delivered confidently.

o Gradually increase the intensity of peer pressure during role play to strengthen
coping mechanisms.

Behavioral Goals:

 Develop refusal skills and confidence in social settings.

 Teach behavioral substitution (e.g., bringing a non-alcoholic drink to focus on).

Challenges:

 The client may struggle with anxiety or give in during role play. Use graduated exposure,
rewarding progress toward staying sober in simulated scenarios.
3. Self-Harm in Adolescents with Depression

Scenario:
A 16-year-old with depression engages in self-harm (e.g., cutting) to cope with overwhelming
emotions, often triggered by academic stress and family conflicts.

Activity Setup:

 Participants: Adolescent, therapist, and a simulated family member (acted by a therapist).

 Role Play Structure:

o Simulate an argument with a family member or receiving a poor grade.

o Teach the adolescent to identify triggers and use self-management strategies, such
as journaling or grounding techniques.

o The family member practices expressing support without judgment, guided by the
therapist.

Behavioral Goals:

 Replace self-harm with adaptive coping mechanisms.

 Improve family communication to reduce conflict-driven triggers.

Challenges:

 Emotional distress during role play may require the therapist to pause and provide
reassurance. Techniques like deep breathing or guided imagery are introduced.

4. Parental Anxiety in the NICU: Fear-Driven Avoidance

Scenario:
A mother refuses to touch her premature baby in the NICU, fearing she might harm the infant. This
prevents bonding and delays the mother’s involvement in caregiving tasks.

Activity Setup:

 Participants: Mother, therapist, and nurse.

 Role Play Structure:

o Begin by simulating simple interactions, such as sitting beside the incubator and
talking to the baby.

o Gradually progress to more hands-on tasks like diaper changing or skin-to-skin

contact under guidance.

o Use verbal affirmations and photo/video documentation to highlight progress.

Behavioral Goals:

 Build the mother’s confidence and reduce avoidance behaviors.

 Strengthen emotional connection with the baby to foster long-term involvement.

Challenges:

 The mother may experience emotional breakdowns, requiring the therapist to provide
supportive psychoeducation about the baby’s resilience.

5. Workplace Reintegration After Trauma

Scenario:
A 40-year-old teacher develops severe anxiety and avoidance behaviors after witnessing a violent
incident at school. They refuse to return to work, fearing a repeat event.

Activity Setup:

 Participants: Client and therapist.

 Role Play Structure:

o Simulate progressively challenging scenarios:

 Walking near the school.

 Sitting in an empty classroom.

 Interacting with a small group of students.

o Pair exposure with relaxation techniques, such as deep breathing or progressive

muscle relaxation.

Behavioral Goals:

 Reduce avoidance through graded exposure.

 Reinforce the use of coping skills during simulated scenarios.

Challenges:

 The client may exhibit panic symptoms during exposure. Reassure and reset the intensity of
the role-play scenario as needed.

6. Caregiver Dependency in Stroke Rehabilitation

Scenario:
A 65-year-old stroke survivor relies heavily on family for basic tasks like eating and dressing, despite
being physically capable. Family members inadvertently reinforce dependency by taking over these
tasks.

Activity Setup:

 Participants: Client, family members, and therapist.

 Role Play Structure:

o Teach family members to provide prompts and encouragement instead of

performing tasks.
 o Simulate scenarios where the client is guided to complete tasks independently, with
family observing or providing minimal support.

Behavioral Goals:

 Increase the client’s independence in daily activities.

 Educate family members on the importance of fostering self-reliance.

Challenges:

 Family members may resist due to guilt or concern. The therapist uses motivational
interviewing to address their hesitations.