Positive behavourial support
The main focus of PBS is to develop behaviour support programmes or plans that aim to improve someone’s quality of life. The plans identify triggers for the behaviour that challenges and find ways to help the people being supported to manage their behaviour in positive ways.
The plans are created through collaboration of the whole care team, the individual being supported and family and, or carers. The PBS plans are evaluated and reviewed to monitor a person’s individual progress and the effectiveness of the PBS plan.
When supporting people whose behaviour is described as challenging, staff across all patient groups should be guided by the values and principles of PBS which:
- Seek to improve the individuals quality of life, not just focussing on behavioural change in isolation.
- Adopt a person-centred, individually-tailored approach.
- Seek to understand why, when and how behaviours happen and what purposes they serve for the individual.
- Focus on altering triggers for the behaviour to reduce the likelihood of behaviour occurring in the first place.
- Where appropriate to the individual’s needs, uses skills teaching as a proactive intervention.
- Use changes in quality of life as both an intervention and an outcome measure.
- Have a long-term focus as behavioural challenges are often of a long-term nature.
- Successful interventions therefore need to be maintained over a prolonged period.
- Adopt a comprehensive range of interventions acknowledging that there are multiple and varied reasons why service users present with behavioural challenges.
- Seek to avoid inflicting harm (physical, emotional, psychological) that is in any way preventable with the aim of eliminating the use of punitive approaches.
- Ensure there are both primary strategies for changing behaviour and secondary and tertiary elements for managing behaviour when it occurs.
- Always adopt the least restrictive, least intrusive approach possible.
- Seek to maintain dignity and respect for the person.
- Promote compassionate care and support.
- See reductions in behavioural challenges achieved as result of the above.
Primary interventions
What are they?
- Interventions designed to reduce the probability of the target behaviour occurring in the first instance.
- Primary interventions normally take place at times when there is no sign of the target behaviour being exhibited.
- Primary plans are focused on preventing occurrences of the target behaviour through a range of strategies some of which are described below.
Changing the person’s environment to better fit the person’s characteristics and needs. This means addressing any issues where there is conflict between the service user’s needs and the environment they are in.
This includes such things as:
Addressing any interpersonal issues.
- Providing meaningful activity.
- Providing access to engaging materials.
- Ensuring appropriate daily routines.
Positive programming.
Providing opportunities for individuals to discover, practice and learn new skills.
This includes such things as:
- Changes in levels of opportunities available to the client.
- Teaching opportunities to increase general skills.
- Teaching skills directly related to the behaviour for example ‘anger management’ (functionally related skills).
- Coping and tolerance strategies.
- Teaching skills that replace the behaviour, e.g. if the function of the behaviours is to get help then the person will be taught to ask or sign for help.
Focused support strategies
Strategies to reduce and, if possible, eliminate the need for a secondary or tertiary strategy.
This includes such things as the use of reinforcing events and talking therapies.
Secondary interventions
What are they?
- Recognising the early stages of a behavioural pattern that is likely to result in the target behaviour and using a range of strategies which must be prescribed in a service user’s intervention plan to hopefully defuse and de-escalate the cycle.
- Where primary interventions are ineffective, secondary or tertiary intervention plans are sometimes needed.
- Secondary intervention plans are concerned only with supporting the person through the first stages of an episode of behaviour that challenges to help them return to a calmer state.
- If secondary interventions are not effective in reducing the behaviour that challenges, tertiary interventions can be implemented.
Types of secondary interventions
De-escalation: Remaining calm and detached with the aim of reducing the level of agitation so discussion becomes an option.
Distraction: A distraction is something that prevents an individual from concentrating on something else.
Breakaway: This is a technique used to assist separation or breakaway from an aggressor in a safe manner.
Tertiary interventions
What are they?
- Tertiary interventions are used if primary and secondary interventions have been ineffective.
Rapid-tranquilisation: The administration of medication for the management of acute agitation or aggression.
Segregation: Setting someone apart from others.
Seclusion: Being taken to a place of privacy for quiet, peace and safety.
Physical restraint: An object or device that is not easily removed that restricts movement or normal access to one’s body.
After-incident strategies
What are they ?
- These are interventions designed to reduce the probability of the target behaviour being repeated.
- After-Incident Strategies normally take place at an appropriate time after a Tertiary Stage Process has taken place.They are based on ideas drawn from a type of Psychological Intervention called Mentalisation, which, in essence, helps people to ‘think about thinking’ – their own thinking and that of others and how they connect… and maybe how they don’t connect.
After incident interventions
After such an incident both parties are likely to have strong feelings which may include:
- Anger
- Shame
- Despair or hopelessness
- Depression
- Anxiety
- Uncertainty
Strong feelings such as these tend to make rational thinking difficult and feelings always crowd-out thinking.
After-Incident Interventions always involve an equal, face-to-face meeting of patient and staff.
Before the meeting
- Take time – maybe a few days after the incident – this gives you and the other person space or time to calm down and collect thoughts.
- Let the other person have a say in the time, place and understood- purpose of, the meeting.
- Agree with the person the date and time of the meeting and when it will start and when it will end. If there are to be a series of meetings, agree on this.
The meeting
- Stick to the agreed date and time and length of the meeting.
- For example, ‘OK – we’ll start at 10.00am and end at 11.00am?’.
- End on time but remind the other person that the end of this session is in, say, 15 minutes time.
- Talk it all through.
- Talk directly. Assuming that there is no threat of physical violence, talk directly to the person with whom you have the problem.
- Plan ahead……give information.
- If you take notes – double-check them with the patient and share a copy with them.
- Give information: For example about other possible interventions such as one-to-one counselling.
- Listen and show that you are listening.
Clarifying a misunderstanding
When you need to clarify a misunderstanding in a thoughtful way, here are a few options:
- “I’m sorry if I wasn’t clear earlier. What I actually meant was…”
- “I think there might have been a misunderstanding earlier. Let me explain my point more clearly…”
- “I believe I may not have expressed myself effectively earlier.
- When you said or did ‘X’ I thought that you meant something which perhaps you did not..?