Positive Approaches Journal, Volume 8, Issue 1

Volume 8 ► Issue 1 ► 2019

False Dichotomies in Positive Behavior Support:  One More Time with Emphasis

Linda M. Bambara, Ed. D.

Abstract

In this article I reflect on my personal experiences in the evolution of positive behavior support.  I emphasize that positive behavior support integrates scientifically based behavioral practices, person-centered values, and other theoretical perspectives to address the complex support needs of individuals who present challenging behaviors. Each of these orientations work in concert with one another and should not be separated. Beware of the false dichotomies that cause supporters to argue about the better approach, form allegiances to specific methodologies, rather than the individuals we support, and reject effective practices.

I am truly honored to contribute to the inaugural issue of Positive Approaches.  This provides me with an opportunity to reflect on my over 30-year history in the positive behavior support evolution.  Of course, like many of my contemporaries, my approach was not always positive.  In my first teaching position in a residential school for children and adolescents with emotional and behavior disorders and autism, I demanded compliance.  I praised plenty, but behavioral infractions were met with time outs, seclusion, and physical restraint.  It did not take me long to realize though that my power to positively influence my students, came not from my negative consequences, but through forming positive, genuine, caring relationships with them and honoring their needs.

In the late 1980’s, I came to Lehigh University and directed Lehigh Support for Community Living, a university-based program that provided residential supports to adults with developmental disabilities recently deinstitutionalized from Pennsylvania’s state institutions.  Here, as a young assistant professor, I was faced with the enormous responsibility of facilitating the integration and community acceptance of 18 individuals whose lives had been broken and who communicated their anguish through various forms of self-injury and aggression. It is hard to say where my staff and I drew our strength from to go against conventional practices, but within a few short years, we eliminated all token economy programs and other forms of artificial consequences that were intended to control problem behaviors. “Emergency” restraints, easily misused by staff, were also eliminated.  Reactive, consequence interventions did not reduce the very problem behaviors we sought to reduce, but rather exacerbated them.

A change in approach, a positive approach, was needed, and I, like many of my colleagues nationwide, drew from a variety of sources.  I was influenced by Ted Carr and Mark Durand, behavioral scientists who documented through various research studies that challenging behavior is communicative, and can be eliminated by teaching people alternative means of expressing their needs.  They also made it clear that non-functional interventions, such as imposed punishment or rewards, are nonsensical if the intervention does not address the underlying function of behavior or change problematic contexts that created the need for challenging behaviors. I was also influenced by Herb Lovett, clinical psychologist and disability advocate, who argued that meaningful change, requires understanding people’s histories and social context, learning to listen to the what and how of people’s communication, and responding in ways that maintain personal dignity and respect in ways that all of us want to be treated.  Leaders of the person-centered planning and community integration movements, such as Beth Mount, John O’Brien, Marsha Forrest, and Steve Taylor, were also strongly influential.  Their messages about building capacity rather than remediating deficits and improving quality of life revolutionized the types of supports offered to people with developmental disabilities.  The synergy of all these influences from different orientations gave birth to positive behavior support, or positive approaches as known in Pennsylvania. In the mid-late 90’s, I was a member of the state’s Positive Approaches Committee that was responsible for changing state regulations for residential settings by delimiting or prohibiting “restrictive interventions,” including the use of non-functional rewards, restraints, and seclusion.  As one of the first states to establish policy on restrictive interventions, I proudly wore a “PA in PA” pin (Positive Approaches in Pennsylvania) at national conferences for all to see.

The evolution toward positive behavior support was not met without any controversy.  At first, many argued against the complete elimination of aversives, for after all, some people who present the most extreme challenging behaviors might need it, the logic went. Overtime as professionals gained confidence by making meaningful changes for people with disabilities with difficult behaviors through prevention, teaching, and lifestyle change, arguments about the need for aversive interventions were repudiated and the positive behavior support movement gained nation-wide acceptance. In a seminal article, Positive Behavior Support: Evolution of an Applied Science, Carr and colleagues¹, argued that the uniqueness of positive behavior support rests on the integration of multiple approaches and perspectives (e.g., person-centered planning, systems theory) with an applied science rooted in applied behavior analysis.  These various approaches, they explained, are integrated into a cohesive whole with the primary goal of improving the quality life and happiness of people with developmental disabilities and the secondary goal of reducing problem behavior.

In other words, positive behavior support is a mash-up of scientifically based behavioral practices, person-centered values, and other theoretical orientations, driven by a comprehensive understanding of individual needs.  This makes sense to me, but as soon as these thoughts on PBS were promulgated, a new form of controversy emerged which continues to exist in various forms today. People often like to argue about what is the better, more positive approach, and in the upshot often lose perspective on the most important thing: the lives of people with disabilities. In my article, Are you a Behaviorist or Bonder?², I wrote about the false dichotomies within the positive behavior support movement that divides us.  Do you ascribe to a behavioral, scientific position or a more person-centered, relationship-oriented position when supporting people with disabilities?  Are you a follower of Herb Lovett or Ted Carr?  Do you ascribe to trauma informed care? Dual diagnoses interventions? Should we use only evidence-based practices in our work, or do you reject scientific practices because of their limitations?  These dichotomies, intentionally created or not, cause us to form allegiances around certain approaches rather than form an allegiance to the people we are called upon to support.  People with disabilities deserve the best, and we are best when we are informed by what works and what truly makes a difference in their lives. 

Beware of false dichotomies. Positive behavior support is the marriage between person-centered values, scientific practices, and different theoretical orientations.  These constructs work in coordination with one another and are not meant to be opposing forces. Person-centered values ensure that the supports and services we provide to people with disabilities are meaningful to them and contributes to their happiness.  Person-centered values guide us to consider people’s preferences, hopes and dreams, make changes to improve their quality of life, and treat them respectfully.  The actions taken from a person-centered perspective can by itself reduce challenging behaviors by making positive lifestyle changes, but for many individuals with complex support needs, it is not enough.  I know of loving families who provide the best for their children and still struggle with their children’s difficult behaviors.  Such families would benefit from behavioral strategies to first identify factors that are contributing to challenging behaviors, and then learn how to prevent problem behaviors by making environmental adaptations and teaching specific skills so that their children can cope with difficulties, better communicate, or better control their environments in ways that others can accept and understand. Being person-centered, does not necessarily mean that professionals and families intuitively know how to address the needs of individuals with challenging behaviors even in the best of environments.  Further, values in the absence of scientifically based practices, can lead families and professionals down a perilous path of selecting interventions based on hopes and beliefs, and maybe the testimonials from others, without a shred of evidence of effectiveness.  The autism field, in particular, is replete with unsubstantiated “treatments” that are not only ineffective, but potentially harmful.

On the other hand, the implementation of scientifically based practices in the absence of person-centered values, can create equally disastrous outcomes for people with disabilities and their families.  It is true that of all the intervention approaches developed to teach people with disabilities new skills and reduce problem behaviors, applied behavior analysis-based methods are highly and perhaps, most effective.³ However, in the absence of person-centered values, the application of behavioral approaches can miss the big picture, and trivialize the intervention.  For example, we can easily teach a young man working in a sheltered workshop to appropriately request staff assistance when bored, rather than screaming, however, if the big picture is missed—the young man is bored out of his mind doing repetitive tasks—then what has been accomplished?  In this scenario I predict that the young man would repeatedly request staff attention, albeit appropriately for a while, until the staff find his constant requests intolerable, they ignore him, and then he reverts back to problem behaviors.  One of the chief criticisms of behavioral interventions, is not that they are ineffective, but that they are often not well integrated into a meaningful whole of a person’s life, resulting in socially unacceptable, and at times morally abhorrent practices (e.g., electric shock), causing some supporters to reject anything behavioral. However, it is not that behavioral approaches per se are faulty, but the way they have been applied.  Applied behavior analysis is not a set of discrete techniques, a pre-packaged program or curriculum.  Rather it is a scientific process that guides us to understand and then positively influence human behavior.  It offers a systematic way of comprehensively understanding and changing problematic situations at both proximal (immediately surrounding the person) and distal (broader contextual factors) levels of support. When used within the context of person-centered values and applied in ecologically valid ways to improve quality of life, the form of intervention changes, resulting in powerful and meaningful outcomes for people with disabilities as documented by a vast volume of research.

Finally, person-centered values and behaviorally based scientific practices do not hold all the answers, opening PBS to integrate other theoretical perspectives.   For example, systems theory, ecological psychology, and community psychology have had a huge impact on positive behavior support¹.  These perspectives have been responsible for the multi-tiered systems of support in school-wide positive behavior support, collaborations with families and other stakeholders, and the idea that supporting the people who support individuals with challenging behaviors is essential for success.  Opening ourselves to well informed, but different theoretical frameworks requires a certain amount of humility to know what we do not know, so that we can learn from one another. This does not mean that we reject the basic precepts of PBS, but rather seek to integrate new ideas and approaches to improve and expand supports.

In summary, positive behavior support is an evolving practice that integrates person-centered values with behaviorally based scientific practices and other theoretical orientations to address the comprehensive needs of individuals with developmental disabilities. At the heart of positive behavior support is the person we are seeking to support. Our allegiance is to that person, requiring us to be person-centered while drawing from the most effective approaches science and our collective professional wisdom has to offer.

 

References

1. Carr, E. G., Dunlap, G., Horner, R. H., et al. Positive behavior support: Evolution of an applied science. Journal of Positive behavior Interventions 2002;4(1):4-16.

2. Bambara, L. M. Are you a behaviorist or a bonder? Smashing artificial dichotomies and entering into a dialogue of shared knowledge and multiple perspectives. Journal of Positive Behavior Interventions 2002;4(1):17-20.

3. Smith, T., & Iadarola, S. Evidence base update for autism spectrum disorder. Journal of Clinical Child & Adolescent Psychology 2015;44(6):897-922.