Influences and origins
PBS is one of a range of person-centred approaches which are complementary, but which are not simply interchangeable. In common with other Person-centred approaches, PBS is ultimately focussed on achieving good quality of life outcomes based on a vision of a better life, a vision developed together with the person (and with the person’s supporters). Like other Person-centred approaches, PBS has been influenced in a general sense by human rights movements and, particularly, by the civil rights movements in the United States. Another strand of influence has been the normalisation movement and social role valorisation (Wolfensberger 1983). However, in addition to these values-based influences, PBS draws heavily from the science of human behaviour and, especially, Applied Behaviour Analysis (ABA).
It should be acknowledged that PBS also developed in reaction to some of the earlier attempts in the 1970s and 1980s to implement the principles of behavioural science within services for people with disabilities. In particular, there was a reaction against practices that seemed more focussed on the suppression of unwanted behaviours, rather than on quality-of-life outcomes, and against punitive interventions. PBS rejected the use of punishment from the outset (e.g., Donnellan et al. 1988). Some of these earlier interventions ‘went wild’ and continue to flourish in a distorted fashion in some of our service settings. We may still observe distressing behaviour dismissed as ‘attention-seeking’, being told that it is best ignored. David Pitonyak (www.dimagine.com) suggests the analogy of a crewmember advising a drowning passenger who has fallen overboard from the ship, that he won’t do anything to help him until he stops flailing about and shouting.
PBS also draws from the principles and insights of family and social systems theory (Lucyshyn et al. 2002a). The social context is always a key part of the assessment and must always inform the design of supports and interventions if they are to be sustainable and of value.
Positive Behaviour Support plans define changes in our own behaviour. Change is not something we do to other people. If we can change what we ourselves are doing in a selective way it will create the space, opportunity and incentive for others to change. This is not to suggest that what we are doing now is wrong or bad.
For example, a parent will often find that what works well with one child is counter-productive with another. When we think about this it is not at all surprising that the other person’s behaviour may change in response to our change, often in surprising ways. If I stop nagging my significant other about what I want her to do—or not to do—and instead express my appreciation for what she does (or do some of the things myself, graciously), then new possibilities can evolve (memo to self here).
A Positive Behaviour Support plan may be based on the most rigorous behavioural analysis and be technically sound to the highest order, but it is unlikely to be implemented and sustained unless it is ‘contextually fit’. A good plan makes accommodations for all the factors in the physical, social, cultural and programmatic environment in which the person is supported. At the more obvious level, what might be workable and acceptable in a family home may not be so in a classroom of 25 pupils, or vice versa. But at the more micro.level, all contexts differ significantly. Each family is unique—structure, values, aspirations, strengths, stressors, distractions, external supports, etc all vary. Direct support teams in service settings will similarly vary.
Various models have been developed to incorporate good contextual fit into the development of PBS plans. Lucyshyn et al. (2002b) describe a family-centred approach to the development of behaviour support plans. The practitioner brings specialist skills, but works in a collaborative partnership with the family in a way that empowers them to develop their own plan with sufficient advice to ensure that it is technically sound. To me, this acknowledges the family members as the experts. The practitioner is the specialist (i.e., someone who knows an awful lot about very little).
Person-Focussed Training (McClean et al. 2005) is a model in which a staff member, who works directly with an individual whose behaviour challenges, is trained to conduct an assessment, to design a behavioural support plan and to implement the plan in collaboration with his/her colleagues. Implementation requires the commitment of the staff team and management, needs to be positively monitored on an ongoing basis, and, of course, plans must be reviewed and updated regularly. Within the organisation that pays my mortgage, the experience has been that staff teams generally welcome and need some level of on-going support from a behavioural support practitioner.
Why do we need an assessment? Because each individual is unique, each context is unique, each family is unique and each support system is unique.
The assessment process must always include a functional assessment. This follows from the behavioural understanding that all behaviour communicates a message. Halle (1994) asserted that ‘our goal must change from the elimination of problem behaviours to understanding their function so that we can craft an intervention designed to teach a new form of behaviour that is at least as successful in achieving the identified function of the old more coercive form.’ Recordings and direct observations of the person and of the contexts in which the behaviour occurs—and does not occur—are key to the functional assessment.
However, assessment needs to be broader than this. We must build up a clear understanding of the person—what is important to the person, what does he/she value, like, dislike, what have been the key events in life up to now, what are the person’s strengths and aspirations, how does he/she relax, get excitement, engage with other people? What about friendship and intimacy? What about the person’s health—physical and mental? What about the environment—how accommodating is it for the person’s needs? What about family, staff or other supporters? What are their strengths, aspirations, stressors, etc? This may all sound like a demanding process, but it is a necessary one. Otherwise a plan is like a house built on sand.
Multi-element support plan
Following from the understanding developed during the assessment, a plan is developed to support the person. A good support plan is likely to have multiple elements because: functional assessment usually reveals that the behaviour occurs in a variety of contexts (e.g., at times of transition, hunger, high sensory arousal, low engagement), following a number of triggers (e.g., a request, someone coming too close too quickly), and is followed by consequences which strengthen or maintain the behaviour (e.g., people move away, people approach):
Multiple responses are necessary to address all of the factors identified in the assessment and to facilitate progress in accordance with the aspirations of the person and his/her supporters.
A typical plan might address changes in the person’s physical environment, the choices and opportunities that are available to the person and how they are presented, how people engage with and communicate with the person in a way that is mutually comprehensible, fulfilling and productive, how the person can be supported to learn alternative ways to communicate the message contained in the behaviours of concern, ways to build rewarding relationships, developing positive social roles, etc. But there is no menu to be copied. The plan is person-specific. If there are risks identified for the person, or for others, then the plan will have reactive management strategies to promote safety for all.
Getting a life
Unfortunately, sometimes people rely on services that offer little in terms of opportunity for valued activities, autonomy and choice, positive relationships or attention to individual needs. The primary outcome that anyone in such circumstances requires is an opportunity for a life—not a behaviour support plan. However, the evidence suggests that when patterns of challenging behaviour are long established, then simply moving a person from one service setting or model to another will generally not, in itself, resolve the behavioural challenges (e.g., Kon et al. 1997; Young et al. 1998). Changing the value base is necessary—vital—but not in itself sufficient. Other requirements include staff who are appropriately trained and managed, specialist challenging behaviour support, and access to good mental health services (Mansell 2007). Tony Osgood (2004) observes: ‘Unless you get to the underlying difficulty, unless you realize that services mean engineering social and professional support, skill building and education around the person and their relationships, you’ll not resolve challenging behaviour.’ And commitment must be sustained. Plans need to be amended and updated as circumstances change or new information emerges, and implementation needs to be supported. Training is too costly to let the results wither and decay. More importantly, people’s lives are too valuable to be wasted or to be lived in despair.