This article is featured in the Winter 2024 issue of Touching Base, our quarterly newsletter for professionals in the health and social care sector. If you would like to sign up for this newsletter, use the form at the bottom of this page.

In the first edition of Touching Base in April 2023, we outlined three practice themes that we were prioritising for the rest of the year. In this first article of 2024, we will give you an update about our approaches to Positive Behaviour Support and the work that we have undertaken over the last year. We have reviewed all of our policies, guidance, training courses and day-to-day support provided to people and their support teams.

Our approach is now aligned with Gore et al’s 2022 definition of Positive Behaviour Support (PBS), albeit with some caveats. Sense Scotland has always viewed behaviours that challenge as primarily communicative and functional. Behaviours are learnt and subsequently reinforced by others’ responses to them. However, taking into account Gore et al’s view that PBS should never be used ‘to make changes to behaviours that reflect cultural differences, neurodiversity, individual interest, or idiosyncratic expression or functioning, where such behaviours do not impact negatively on health, wellbeing and quality of life’, we are especially mindful to understand and appreciate the life experiences of people supported by Sense Scotland. We recognise that some applications of Positive Behaviour Support might not place sufficient emphasis on the longer-term impacts of attachment and trauma, nor long-term communication and sensory support needs. Sense Scotland’s approach foregrounds all of these against a backdrop of person-centred support.

Over-reliance on simply understanding immediate triggers to explain why someone becomes distressed or anxious might mean that we miss opportunities to look at longer-term issues related to trauma and attachment, particularly if we take into account that many people we support perceive the world around them in fundamentally different ways than members of their support team. What may appear as strange and unusual actions to some become perfectly understandable and indeed crucial when understood from a different sensory perspective. For example, a person who hits out at others as they approach him might have a significant visual impairment that means he doesn’t see people approaching him until the very last minute – no wonder he gets distressed if there was no prior warning. A child who ‘refuses’ to lift their head off the table while engaging in class work directed by a teacher from the front of the class is not being disrespectful but might have found the only way they know how to feel safe and secure because they have issues with their vestibular system (their sense of balance). Years of being surrounded by people who don’t recognise let alone respond to your communication attempts might lead to the type of anxiety that won’t be tackled simply by making a change to the immediate environment or stimuli. So it is absolutely vital that an individual’s communication support needs and sensory perception of the world around them are taken into account at all times. If we do not match our support to people’s needs and experiences then at one level we may miss an opportunity to view someone’s actions as ‘their way of being in the world’, and, at another level, we may contribute more than we would like to imagine to someone’s level of distress and anxiety.

For these reasons, we can see that both partners in any interaction must learn from each other, learn how to understand each other, find out how to negotiate alternative communication skills and strategies and how to get the most out of the world around them. Perhaps, in a future edition of Touching Base, we can explore how we have been inspired to expand Vygostsky’s famous theory of the Zone of Proximal Development to capture the idea that both people have to learn how the other likes to be in the world. And yes – this would include teachers learning from pupils, support workers learning from people they support, and parents learning from their children! If you want a sneak preview of some of these ideas, check out this short introduction. For a longer exploration, check out this video.

At Sense Scotland, we follow a three-tiered approach to support (primary, secondary and tertiary) that allows everyone to benefit from universal, primary-level strategies that maximise communication support and opportunities to engage in meaningful activities, whilst at the same time minimising levels of anxiety and distress that can lead to behaviours that challenge. As an individual’s needs increase, we offer more focused support to that person, their support team and carers.

Space won’t allow us to look at each of these in great detail but in general terms, Sense Scotland routinely offers support in the following ways:

Primary level

 Support offered to everyone:

• Completion of a personal profile when someone is first supported by Sense Scotland. This includes discussion on a person’s likes and dislikes; people, places and activities that are key motivators; existing communication strategies, health and wellbeing support needs, sensory processing details etc.
• Everyone has a detailed ‘My Support Plan’ and associated guidance that describes how to offer high-quality support.
• Everyone has a Health and Wellbeing Log or a detailed Health Section within their My Support Plan.
• Where a person’s communication support needs are changing, a Communication Profile or equivalent can be developed to allow updates to My Support Plan.
• Where a person’s sensory support needs are changing, a Sensory Profile or equivalent can be developed to allow updates to My Support Plan.
• All support plan guidance is reviewed and updated on an ongoing basis and as part of a more formal review process at six monthly intervals.

 

 Secondary level

 Support offered as appropriate if people show increased levels of distress or anxiety

• Functional sensory assessments are completed by staff delegated by Registered Managers or agreed members of our Operational Support Team.
• Functional behaviour assessments (including Behaviours that Challenge Checklist, ABC and Scatter Plot Charts) are completed by key staff throughout the organisation.
• Positive Behaviour Support Plans are commonly written by external agencies and colleagues and we will follow those. Sometimes, however, they may be completed within Sense Scotland by a number of agreed team members.
• Intervention Plans are put in place that detail de-escalation strategies. These plans comprise both long-term (proactive) and short-term (reactive) strategies. Sense Scotland recognises that long-term planning is a crucial element for positive change for the individual concerned. Short-term plans are primarily concerned with conflict avoidance and resolution.  All individuals who exhibit behaviour which may cause harm or limit opportunities should have a behaviour intervention in place.
• Facilitated discussions can take place, centred on how people experience the world – what makes them ‘tick’, personal outcomes, life stories and histories using person-centred thinking tools, Talking Mats or other communication approaches.

 

Tertiary level

Support offered in situations when distress and anxiety manifest through behaviours that may challenge others. Sometimes, this might include agreeing restrictive practices.

We continue to offer all strategies outlined for the primary and secondary levels above, plus agreed Intervention Plans that detail any required restrictive practices, using guidance and definitions published by the Mental Welfare Commission (Right, Risks and Limits to Freedom 2021). We recognise that some incidents of behaviours that challenge may require the use of a restrictive practice to avoid injury or harm to the individual concerned or to others and we take seriously our obligations to the people using our services arising from the Regulation of Care (Scotland) Act 2001 and the Human Rights Act 1998. We are committed to safe practices and safety in environments.

Training materials from CALM Training Services highlight the long history of people and organisations arguing for restraint reduction, leading to their view that ‘reducing or eliminating restraint…(is a)…‘no brainer’’. This is why, over this past year, we have participated in workshops and discussions led by Restraint Reduction Scotland. The literature is full of negative outcomes arising from the use of restraint, including serious injury and fatalities, the negative impact on people being restrained and also on staff using restraint. Within Sense Scotland, restrictive practices can only ever be used as a last resort and must be part of a wider support plan which takes account of the individual’s sensory impairments, communication support needs and other abilities and must be supported by a risk assessment. Interventions must demonstrate how they are of benefit to the individual, be the least restrictive and take into account the person’s wishes and the views of other interested parties. We have audited every single restrictive practice in place across our services over the last year to replace as many as possible with alternative strategies.

Sense Scotland’s training and support for staff is also aligned with the three-tiered approach. We are mindful of advice from others not simply to see training as an easy solution for staff to become more skilled and not simply to see education and training, particularly around de-escalation and breakaway skills, as the way to reduce the use of restrictive practices. Instead, we are re-energising our approaches around communication support, building relationships, understanding how a person perceives their world, activity and environmental design and support planning. We are keen also to build on the work being done in our field around ‘capable environments’ (McGill et al, 2020) and developing practices related to trauma-informed organisations (NES, 2016 and 2017).

Primary (All Staff)

• Core mandatory training including human rights, inclusive communication, safeguarding, core values etc.
• Role mandatory training linked to specific health, communication and sensory needs of people supported.
• Support Planning.

 

Secondary

• Specialised communication courses linked to people supported (e.g. Makaton, British Sign Language (BSL), Boardmaker etc).
• Autism awareness.
• Sensory impairment courses at various levels ranging across sensory integration, vision, hearing, touch, proprioception, and vestibular system.
• Escapes and Breakaways courses are offered by our CALM instructors trained by CALM Training Services.
• Understanding Communicative Behaviours (Sense Scotland one-day course) – mandatory for various staff groups, including any staff supporting someone who manifests distress and anxiety through behaviours that challenge.

 

Tertiary

• Courses on functional sensory assessment have recently been introduced and are available to key groups of staff.
• Additional specialist communication courses are being introduced throughout 2024.
• CALM Theory course – mandatory for all staff supporting a person who has agreed physical interventions in place.
• CALM physical intervention course offering support to learn only any agreed CALM techniques for any person supported.

 

Sense Scotland also recognises the physical and emotional stresses that may be associated with supporting individuals who present behaviours that challenge. Staff are supported through regular supervision meetings and, as appropriate, asked to participate in debriefing sessions after particularly challenging incidents.

Our new policies and guidance launched in October 2023 and, throughout 2024, we will measure the impact of these changes using a variety of tools, including our Quality Audit processes, reviewing daily diaries, regular use of our support plan self-evaluation tool which provides qualitative data on how well interventions are implemented, the appropriateness of language used in support plans or positive behaviour support plans are written (using a simple ‘Above / Below the line’ checklist) and progress towards personal outcomes for people we support.

Throughout this journey, we must be clear that getting support right for a person is not just about interventions related to times when they are distressed, but rather it is about the values we adopt every day, our safeguarding approaches, the language we use, the way we interact with people on every occasion, the choices we hear and act upon, the stories we tell about people, the environments people live in and the people and places they visit. Positive Behaviour Support is not just something for one policy document – it should be in all our policy documents.

That leaves us with our final thought at this stage and where our journey is taking us – given that effective PBS is related to everything we do, in time perhaps Sense Scotland and our field in general will move away from relating it to ‘behaviour’ to all, and simply think about how we can all offer positive support.

If you have any questions or would like to follow-up on any ideas presented in this article, please get in touch. We would love to hear from you.

Written by Dr Paul Hart, Head of Operational Support, Practice Development and Quality