Fear of incontinence and its effects on a community-based rehabilitation programme after severe brain injury: Successful remediation of escape behaviour using behaviour modification

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Abstract
The presence of continence problems following severe traumatic brain injury may be attributable to either organic or psychological factors. In the case of the latter this in turn may lead to the development of behaviours that result in avoidance of or escape from rehabilitation activities. In this paper, a single case study is described in which verbalized fear of incontinence prevented participation within a community rehabilitation programme. Assessment suggested that behaviours that led to escape from this programme were being maintained by negative reinforcement through reduction in anxiety associated with this activity. An intervention was implemented using graded exposure and differential reinforcement of incompatible behaviour. Treatment led to a significant reduction in escape behaviour; this had been maintained and consolidated further at 9-month follow-up. However, no change occurred to the client's prompted self-ratings of anxiety. Reasons for the discrepancy between improvement in behaviour but not self-report are discussed. The potential limitations of using cognitive-behavioural therapy with some survivors of severe traumatic brain injury are also discussed. Finally, comments are made concerning the applicability of the treatment techniques described here in the modification of escape and avoidance behaviours that may be acquired following brain injury.