The growing interest in PBS is amazing. It has been mentioned in government policy as an identified solution to reduce restrictive practices and end abusive practices, such as those seen at Winterbourne View. It has been recognised as a model that can improve the outcomes and quality of life for people with some of the most complex needs. However, it continues to remain unclearly defined. The increase in popularity is leading to more and more providers and practitioners saying that they do PBS, and few people appear able to critique this and review how PBS a “PBS service” is. I hope this provides some support in this, or at least encourages further debate.
I will list hear things that should not be said as part of PBS. I need to be clear – I am not saying these things should never be said or are wrong. They may be a valid part of another intervention, but they are not PBS. There also may be times when a person needs a PBS plan and another plan that may include some of the things here. It is my view we should clearly separate in these situations what is PBS and what is not. This will help clarify what defines PBS and what does not. This is a key time for PBS in the UK. If we get it right we can achieve some great things. If we dont it will be written off as re-hashing the same old stuff. I welcome comments and feedback and will update the list as required.
1. “Here is the plan to reduce X’s challenging behaviour”
Plans to reduce behaviour are called Punishment interventions. PBS adamantly avoids the use of punishment. A PBS plan aims to support the person to learn functionally equivalent behaviours – ways of achieving the same things the behaviour of concern achieves, but in less distressing ways. The behaviours of concern then reduce as a naturally occurring side effect. Reductive procedures are part of Behaviour Modification. The statement of PBS being anti punishment is often confused with PBS being anti the use of aversives and anti the use of abusive practices – the use of things that people don’t like and abusive practices is wrong in anyones eyes and should be avoided for these reasons alone, not just in the name of PBS. PBS avoids punishment by not focussing on reducing behaviours, but focussing on increasing other behaviours instead.
2. “The plan is split into Primary responses to the behaviour, Secondary responses to the behaviour, and Reactive responses to the behaviour”
The issue here is that the focus is on the behaviour and not on the function. Focussing on behaviours of concern leads to people being stuck with labels relating to their behaviour that are very difficult to shake. It leads to supports being focussed on the problem behaviour and in a constant defensive stance. In PBS the focus is on the function. Plans look a lot different when they are written from the perspective of “The function X is trying to achieve is avoiding unpleasant tasks” than when they start from “X punches supports in the face when asked to have a shower”. This Primary, Secondary, and Reactive approach is risk management planning. We do a functional assessment in order to create a functional plan.
3. “Its all about environment and antecedents”
Antecedents and environments are important, but if plans are only focussed on this they can do more harm than good. Imagine if a person has a fear of dogs and everytime they see a dog they hurt themselves or run. The answer based solely on antecedents would be to never leave the house so they never have to encounter a dog, and this is not beneficial as a life long solution. There is a great rap by Dr Merril Winston on the perils of antecedent manipulation which can be seen here: https://www.youtube.com/watch?v=32yNVGCrUSk. A PBS plan should consider how the environment can be adapted to help the person achieve the function easier (The A’s), teaching new skills so the old behaviours aren’t necessary (the B’s) and how to ensure these new behaviours receive effective reinforcement (the C’s)
4. “I dont believe in reinforcement schedules”
Whether we like it or not, we all live day to day based upon receiving reinforcement. We go to work to get paid, we interact with others because it gives us social reinforcement, we eat to be reinforced by nice tastes and to meet our need for food. Designing reinforcement schedules is complex and requires a thorough understanding of the underpinning science to get them right. They also only have a short term effect so need to be designed with plans for maintenance and generalisation in mind. But essentially they are the prosthetics of an intervention that leads to learning and motivation to learn. To deny people with disabilities in learning these prosthetics is akin to denying a blind man his guide dog. There are criticisms by services for adults that these can be childish, but this is merely a lack of imagination and creativity.
5. “It may not work, or it may take a long time to achieve”
There are often not quick answers and it may take a long time to achieve, this is true. This is why collecting data is an important part of PBS. Often the changes are slow and small. Keeping data on these changes helps keep track of what small steps we are trying to achieve and helps support around the person see progress is happening. If it doesn’t work we haven’t got the function right so its back to the assessment.
6. “PBS can be done by anyone.”
PBS is everyone’s business and needs support from the the whole system the person is part of (by system I am referring to direct supports, immediate living environment, activities, community, and the socio-political landscape). But it is also a clinical intervention. It requires people who are skilled and competent in the underpinning science to lead and devise plans. Without this it ends up being a plan for being nice to the person, with no developmental direction and no focus on the function of behaviours of concern.
7. “PBS is nothing to do with ABA”
PBS is the science of ABA with the values of Person Centred Planning and Normalisation. As above, without the underpinning science it is little more than plans for being nice. We all benefit from people being nice, but these plans need to be devised with an understanding of reinforcement schedules and detailed functional assessment of complex behaviours that are not easily understood without this assessment. There should be a professional somewhere in the system who is registered with a professional body (BACB, NMC, HCPC) trained to MSc level or above in behavioural science. This is regardless of what professional title they may have. PBS without ABA is not PBS. This is the recommended level of training by BACB and there are many professionals in the UK who have this level of training but do not register with BACB as they are already registered with another professional body. This is the level of training required to be fully competent in functional analysis which underpins PBS. Others can be skilled in using the tools and undertaking the work but it will need this level of training for supervision and analysis in complex situations. We need to be aiming for different levels of competence for PBS in the UK, similar to how you will find different levels of competence in CBT in mental health services, but not to ignore the clinical skills that are required in the overall delivery. There is work underway to address this in the UK at present. We would not accept heart surgery from an unsupervised theatre nurse because she knows what tools the surgeon uses, why is it ok to accept people with learning disability and incredibly complex behaviours that can be life threatening receive less?
8. “The evidence for PBS is limited”.
There is some truth to this. As PBS is largely weak in its definition in the UK it can be hard to tell from studies whether the interventions used have stuck with the principles of PBS or not. However, Willis & LaVigna conducted a review in 2012 (http://www.ncbi.nlm.nih.gov/pubmed/22774760) which demonsrated its effectiveness. As previously stated, PBS is based upon the science of ABA which has nearly 60 years of evidence behind it and is recognised as the most evidence based intervention in learning disability practice.
9. “PBS is against restrictive interventions”
A PBS plan should be largely proactive plans about how the person will learn functionally equivalent behaviours, which make the problem behaviours not needed as a naturally occurring side effect. There is then a very clear distinguishing line between the proactive plans and the reactive plans. Reactive plans that are part of a PBS plan should be totally non-aversive (i.e. not disliked by the person) and aim to reduce the severity of the incident as soon as possible. Learning for future occurrences is totally disregarded as times of distress are not when people learn. It may be that the behaviours are so severe and so harmful that restrictive interventions are necessary. These are ok but they are not part of a PBS plan, they are a restrictive interventions plan. A person can have a PBS plan and a restrictive intervention plan at the same time. Ideally the restrictive plan should include plans to reduce its use as the PBS plan comes into effect.
10. “PBS does not work with other interventions”
As PBS is underpinned by the science of ABA, and the science of ABA underpins everything that people do it can incorporate any other evidence based intervention into this model. It doesn’t conflict with other models/approaches, it isn’t exclusive and doesn’t assume nothing else can be tried whilst this happens. It doesn’t ignore the role of multi-professional working, e.g. the role of Speech & Language Therapists/Occupational Therapists/Physiotherapists. In fact it embraces this as part of a holistic plan. It works in partnership with other approaches, such as Active Support, which is also based upon behavioural science. The overall focus of support for people with learning disability needs to be on Enablement. This requires supportive environments that mitigate the effect of a person’s disabilities, and skilled approaches to supporting the person to learn new skills that enable independence. PBS is one of many approaches that embraces this. It works in partnership with other approaches as an overall model for Enablement. Seeing it as competing with other approaches demonstrates an immature, professionally protective standpoint that has poor understanding of the underpinning science.
These are my immediate thoughts on the key things you shouldn’t hear said as part of PBS. I appreciate with the current position of PBS in the UK that these views may not be widely accepted by everyone and I welcome discussion and debate on this as I feel this will lead to a clearer definition of where PBS is and what it could be in the future.