After a brain injury, a useful alternative to the natural development of executive functions (EF) having to do with inhibition and emotional self-control is the reinforcement of rules that prohibit target behaviors.

Using prohibitions to develop self-control is useful because it simulates the down-regulation of the limbic system by the orbital-frontal cortex (OFC). The OFC is linked to the amygdala such that it provides appraisal-based inhibition (ABI) after arousal.

When the person with ABI doesn’t have enough “self-control”, one likely cause is an imbalance between the OFC and the limbic system, which had been gradually developed through mid-childhood and early adolescence, but has been disrupted by the ABI. One helpful way to think of this is to evaluate these executive functions in terms of age equivalence and then to design rules and procedures that would be appropriate in a school setting for people of that age.

Get started with the Behavior Rating Inventory of Executive Function—Adult (Roth, Isquith, & Gioia, 2005) administered to both the person and a significant other. Because age-based normative data are available, you can help the client and family understand that this is a developmental issue, which is often greatly appreciated. Once the emotional self-control level has been identified, functional-age-equivalent rules can be developed that are more likely to be successful in eliciting appropriate behavior.

Care should be taken to not over-restrict the client because the “just-right challenge” is found at the interface between his or her immediate capacity and the demands of their occupations and environmental contexts. You want to continue to challenge the client so that self-reliance is able to gradually develop. One way to do this is with motivational interviewing (Miller & Rose, 2009). MI is a strategy that was developed for counseling persons with drug and alcohol dependence to assist with sobriety. It has been found to be useful whenever ambivalence pertains, which is usually the case with ABI intervention. The beauty of a vocational context for MI is that the “urge towards competence” (White, 1959; White, 1971) is always operative, reinforcing the clinician’s efforts.