Sometimes, particularly with adolescents, a person has not learned the appropriate skills. Shaping is often used when teaching new skills. This involves providing rewards for successive approximations of the skill. Many people are not able to learn the whole skill at one time, and will benefit from learning the "baby steps" one at a time. Two commonly used strategies are forward chaining and backward chaining. Both involve breaking the activity down into small, achievable steps.
Forward chaining involves teaching the skill starting with the first step. So, the first time, you teach the client to perform the first step, and you perform the rest. When your client is able to do that well, teach him or her to perform the first two steps, and you perform the rest. Continue this way until your client is performing all the steps independently.
Backward chaining involves teaching the skill starting with the last step. You start by performing all the steps, up until the last one, which you teach your client to perform independently. When your client is able to do the last step well, you start encouraging your client to do the last two steps. Continue this way until your client is performing all the steps independently.
Backward chaining is often a preferred method of teaching hygiene and grooming skills as it is often very rewarding to the client to be able to complete the finishing steps.
Checklists and Visual Cues
It is important to find out why the hygiene and grooming tasks are not being performed. Often, a person knows how to do them, but is not motivated. Sometimes, the person does not have the appropriate supplies. Sometimes, a person may be able to perform each individual step, but has difficulty putting them all together.
Checklists can help a person remember what needs to be done, and how to put the steps together. A morning routine checklist is commonly used, and sometimes a nighttime routine checklist as well. If you put the checklist in a plastic sleeve or laminate it, it can be re-used with a washable or dry-erase marker. I often purchase self-adhesive vinyl at a dollar store to cover the checklist. I have found that clients often end up taking the page out of a plastic sleeve, so a plastic sleeve does not end up protecting it very well.
A morning routine checklist lists all the activities that need to be done, in the order they need to be done. For example:
- go to the bathroom
- eat breakfast
- get dressed
- brush teeth
- wash face
- brush hair
- take off pajama shirt
- take off pajama pants
- put on underwear
- put on socks
- put on pants
- put on shirt
When a person commonly runs out of personal care products and forgets to purchase new ones, a personal care product checklist may be helpful. List all the supplies a person uses, and then when the person gets close to running out, encourage him or her to place a checkmark next to that item. Then the checklist can be used when creating a shopping list. One problem with this approach is that people often wait until a product has completely run out prior to checking it on the list. If the product comes in bottles (e.g. shampoo), you can use permanent marker to place a mark on the bottle. When the product reaches that level, it needs to be added to the list.
Sometimes signs can be used as visual cues to remind your client of specific activities needing to be done. I had one client who would shower daily, but forget to wash appropriately when he was in the shower, resulting in bad body odor. We created a colorful, laminated sign to post in the shower to remind him to wash his underarms, groin, and feet. Ideally, the color or positioning of the sign would be changed at least weekly to ensure he does not become habituated to it, and stop seeing it.
Sometimes, people are able to get dressed, but are unable to put an outfit together. They may not choose appropriate outfits, or may miss putting on certain items. It can be helpful to have a well-organized closet. This often means ensuring that all items in the closet and/or drawers are for the appropriate season. Clothes for opposite seasons should be packed away. It often means ensuring that clothes for special occasions are also packed away. It can be helpful to put together full outfits, and hang them together on one hanger. This ensures no items are missed, and the clothes match. Items such as underwear and socks can be hung in a bag on the same hanger. This way, the client can go to the closet, choose out a hanger, and know that if he or she puts on all the items, it will be a full, coordinated outfit.
When Motivation is a Problem
When your client knows what to do, but just cannot bring him- or herself to do it, it may be helpful to work with your client to set goals and establish rewards. There are many intrinsic rewards to good hygiene and grooming, which should be reviewed. These include: being attractive to others (making and keeping friends), finding and keeping employment, and finding and keeping a place to live.
It can be helpful to establish specific goals for how often to do hygiene and grooming activities, and to have your client track how often he or she actually does them (using a checklist). Appropriate extrinsic rewards can also be planned e.g. If I have a bath before group, I will go out for coffee with group members afterward. It is important to ensure the goals are a "just right challenge" (check out my blog on it by clicking here).
When Hygiene and Grooming are Still a Problem
If hygiene and grooming continue to be a problem, despite all the attempts to teach the skills or modify the task, it may be appropriate to look for ways to minimize the impact of the poor hygiene. Living in a situation that gives the person a little more space (e.g. his or her own apartment instead of a group home) can make body odor less offensive to others. I heard about one client who found a job working at a sewage treatment plant, where body odor was not a concern. Encouraging your client to meet friends outside instead of in an enclosed space can help to maintain friendships.
Another concern with poor hygiene is that it is often associated with poor housecleaning. A smelly apartment can make a person smell bad, and a smelly person can make an apartment smell bad. I think that lack of motivation can contribute to both situations. You may also want to check out my blog on housecleaning.