i) Professional boundaries

Workers need to maintain boundaries in relationships with clients, especially when issues about sexuality are concerned.

It is useful to be able to recognise covert as well as overt sexual connotations in relationships with clients. Undesirable behaviours may not be frankly sexual. They may be more subtle, like a client's overly familiar greeting, "Helloooo darling, when are you going out with me?"

Limit-setting prevents the client from developing unrealistic fantasies and protects the worker from feeling uncomfortable pressure to accept greater familiarity than is appropriate for a work relationship. It is appropriate to set limits on the relationship in a way that reduces ambiguity for the client and the worker.

Setting boundaries does not mean being distant or unfriendly, but it does mean stating where your boundaries are, e.g. "I like working with you, but I am your worker, not your girlfriend" or "I know you would like to kiss me, but I am your worker, not your girlfriend" or "Workers are not allowed to go to bed with their clients."

Although workers often feel sorry for clients who have become socially isolated after a severe head injury, it is important to remember that any socialising that a worker and a client do together should be named by the worker to the client as part of their working relationship, e.g. "I am taking you to the movies because it is my job; I am not your girlfriend." This reduces ambiguities in the relationship and will help the worker to set limits on unwanted sexual behaviours from the client.

 

ii) Verbal feedback

The study by Simpson et al (1999) suggested that at least a third of incidents of sexually inappropriate behaviour were dealt with verbally. However, it is a specific type of verbal feedback that is likely to be effective.

Give clear, simple and unambiguous feedback, e.g. "no touching" or "masturbate in your bedroom, not in the lounge." A worker can not assume that clients will recognise hints that their behaviour is not appreciated. They need to be told directly.

Feedback must be matter-of-fact and firm, without emotional tones of shock or nervousness or disapproval.

Often, unspoken rules about appropriate social behaviour may need to be spelled out, e.g. "It is not OK. to talk about my breasts."

A prohibition about one behaviour needs to be followed by a clear alternative, e.g. "It is OK. to talk about what you want to do today" or by a distraction. This will help reduce perseveration on the undesired behaviour.

Talking to other workers and family members about the approach being taken and what behaviours are targets for change will help to ensure that the client gets the same message from everyone.

Check a client's understanding of what has been said by asking her or him to repeat the information. This is better than asking "Do you understand?" to which people will almost always say yes, whether or not they do understand. Use this approach with care and sensitivity, as it can easily sound to clients as though they are being treated like children.

 

iii) Other options

Behavioural intervention

A psychologist may be able to help by assessing the problem behaviours and developing a simple behaviour program to control or eliminate the problem (e.g. the scheduled use of rewards to reduce a client’s inappropriate touching behaviours)

Structure environment

Sometimes by structuring the environment, we can minimise the impact of inappropriate sexual behaviours. For example, a man who was grabbing at personal aides when they were showering him only had the use of his Right hand. By putting a washer in that hand, and approaching him from the Left side, this problem was solved.

Medication

In cases of more serious behaviours, medication may sometimes be of help. Depo Provera can reduce male testosterone level and reduce aggressive sexual behaviour. However, it does not work in every case and a doctor will be needed to assess this option.

Separation

In some cases, if the behaviours cannot be controlled in one environment (eg at home), then separation may have to be considered, and placing the person with TBI into another environment. This can help to reduce the impact of those behaviours.

Legal system

In some cases, the police will become involved, and the person charged with a crime. This can sometimes make an impact on the behaviour of the person with TBI, but is only a last resort.