Challenging behaviour in mental-health settings takes many forms, and for many reasons. Examples of challenging behaviour may include stereotypical behaviours such as rocking or pacing but may be far more disruptive to both the person and their carers and families. These behaviours would include physical aggression to themselves and others, property damage and verbal abuse..
When thinking about the causes of challenging behaviours, it is important to consider the environment and wider context in which the behaviour occurs as well as the person’s own internal factors such as physical and emotional well-being, mental health and cognitive abilities. As often as not, they are a combination of these factors. Understanding what brings on challenging behaviour is the first step towards anticipating, preventing or de-escalating it in the most humane, effective and non-punitive way possible, and this is the approach championed by Positive Behaviour Support.
A sea change in attitudes to challenging behaviour has been the evolution over the last 30 years or so of Positive Behaviour Support (PBS) strategies. PBS aims to enhance quality of life by encouraging positive behaviour alternatives to challenging behaviour, rather than simply repressing or punishing behaviour through restrictive interventions.
The bedrock of this thinking is acknowledgment that underlying challenging behaviour is functional: it is done by patients with mental health illnesses for a purpose, such as attracting attention, relieving boredom or manoeuvring out of a situation where the instigator feels uncomfortable or distressed.
If challenging behaviour achieves that objective, it is likely to reinforce the behavioural pattern. Addressing the behaviour through restrictive interventions, such as restraint, seclusion, sedation or withdrawal of favoured activities, may stem the challenge in the short term while doing nothing to address root causes, at times even exacerbating the problem.
Concerns about excessive use of restraint and medication in care settings led to initiatives such as the Department of Health’s guidance of April 2014, Positive and Proactive Care: reducing the need for restrictive interventions. This document for health and social care providers came out strongly in favour of Positive Behaviour Therapy as a positive and proactive approach to understanding and managing challenging behaviour.
The PBS process starts with a basic functional assessment of the individual involved; their personal history; how, when, where and why their challenging behaviour arises; and what the consequences of that behaviour are.
This process is not only person-centred but holistic, looking at every possible factor in an individual’s psychology, needs and environment that might trigger or contribute to incidents of challenging behaviour. It then suggests alternative positive behaviours that can achieve the same objective without presenting a challenge.
Anyone who is dealing with challenging behaviour and is involved in supporting individuals prone to challenging behaviour, including health- and social-care teams, family, carers and service users, should have input into this process. The end result is a personalised, multidisciplinary Positive Behaviour Support plan, which sets out consistent, transparent strategies for identifying, averting and managing challenging behaviour.
The plan includes proactive and reactive strategies to reduce challenging behaviour and improve quality of life. These might encompass changes to the individual’s environment and routine; opportunities to learn new behavioural skills, with an emphasis on coping and repair; de-escalation techniques; and appropriate, ethical responses to minimise risk of harm where behaviour cannot be prevented.
The emphasis is firmly on proactive positive behaviour strategies that redirect challenging into positive behaviour. Once implemented, the plan is monitored and updated to take into account any environmental, circumstantial, emotional or other changes that affect the individual’s propensity for challenging behaviour.
Working with the Centre for the Advancement of Positive Behaviour Support at the British Institute of Learning Disabilities, the Huntercombe Group has been implementing PBS as an integral component of care at its hospitals and centres since April 2017.
So far, 21 out of 23 sites have established PBS practitioners to support their services. The programme continues to gain momentum, with four new PBS coaches for the next financial year. Examples of challenging behaviour encountered by Huntercombe staff vary but they often involve self-harm, aggression or, with brain injuries, distress around personal-care needs.
Positive Behaviour Support training programmes to embed PBS in Huntercombe culture have opened up new ways of thinking about challenging behaviour and restrictive practice at multiple levels of support, including psychologists, doctors, occupational therapists, speech and language therapists, support workers and nurses.
This might be something as straightforward as asking why a door has to be kept shut, or why a toilet is reserved for staff use. Alternatively, it might address more complex issues such as access to mobile phones, tablets and social media.
One example of PBS being successfully applied in Huntercombe’s Eldertree Lodge facility near Stoke-on-Trent was a 55 year-old patient with a high frequency of challenging behaviour, most of it self-harm. This meant the patient missed out on activities she enjoyed, impacting upon her quality of life.
Based on a functional assessment and information from the DATIX system, which records behaviours of concern, the patient was recommended for a Positive Behaviour Support intervention. The main function of self-harm was identified as ‘attention’. Ward staff said the patient was bored and believed staff were rejecting her or had no time to talk with her.
The PBS plan included communication strategies, to ensure the patient felt ‘looked after’, and a PBS timetable providing alternative means of gaining staff attention, such as hand massages, pampering, one-to-one talk time and additional offsite trips.
Before the intervention, the patient was having an average of 25.8 challenging incidents per week. A DATIX sample during the two months post-intervention showed this frequency reduced to an average 4.6 incidents per week.
The Positive Behaviour Support strategies delivered the patient’s desired outcome of more attention and improved her quality of life by enabling more frequent access to the community, where she started to attend weekly coffee mornings at the local church.
A recent cohort study of PBS outcomes at Eldertree Lodge found there had been a 37% reduction in restraints overall since the PBS programme was implemented. Use of the most restrictive forms of restraint fell by 53%, and of the least restrictive restraints by 37%.
Accentuating the positive
Positive Behaviour Support provides a cohesive framework that can be applied flexibly across a variety of contexts. Accentuating the positive in dealing with challenging behaviour helps people with mental health issues make choices that will benefit both themselves and others.
An additional goal of the PBS programme at The Huntercombe Group is a beneficial impact on workforce wellbeing and practice, including stress levels, competence and staff retention. In specialist brain-injury services, for example, PBS implementation has reduced the frequency of distress-related behaviour that puts undue pressure on staff, such as constant ringing of call bells.
By ensuring that Huntercombe actively support people through capable environments that allow more choice, control and empowerment, a person’s quality of life improves, removing the need for challenging behaviours to get their needs met.
 Positive and Proactive Care: reducing the need for restrictive interventions. Department of Health. April 2014. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/300293/JRA_DoH_Guidance_on_RP_web_accessible.pdf.
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