The Nonviolent Crisis Intervention® training program and Positive Behavioral Support (PBIS) offer complementary strategies for providing the best Care, Welfare, Safety, and SecuritySM before, during, and after a crisis situation. This article describes key elements of PBIS, highlights connections and common ground between PBIS and the Nonviolent Crisis Intervention® training program, and provides suggestions and ideas for integrating PBIS strategies into your prevention and intervention plan.
What is PBIS?
Positive Behavioral Support (PBIS) is based on the premise that behavior is a form of communication, and that people use a particular behavior because it is the most effective and efficient way for them to communicate or achieve a desired goal. For example, if having a tantrum (the behavior) brings help faster and easier than asking for help, then a person is more likely to tantrum than to ask for help. Staff members can sometimes be Precipitating Factors to behavior because they may provide what the client is hoping to achieve rather than assisting them in identifying and learning a more appropriate behavior that can achieve the same result in a safer way.
To address this, Positive Behavioral Support involves the assessment and re-engineering of environments to support an individual in reducing challenging behaviors and increasing positive behaviors as well as the quality of their lives (Horner, 2000; Crone & Horner, 2003). Effective support focuses on comprehensive changes in three key areas:
- Environment: Modifying the environment to reduce Precipitating Factors.
- Skill-building: Teaching and increasing clients' skills—so that they choose positive behaviors rather than challenging behaviors.
- Staff Responses: Being aware of how staff responses can be used to reduce behaviors that are not in the best interest of the Care, Welfare, Safety, and SecuritySM of the person or others—AND to support and increase positive behaviors. (Horner, 2000)
How does PBIS relate to the Nonviolent Crisis Intervention® training program?
As discussed in the CPI Crisis Development ModelSM, the behaviors and attitudes of staff members impact the behaviors and attitudes of clients (Crisis Prevention Institute, 2005). In the same way, PBIS strategies focus on how we arrange the environment, teach, support, and respond to behaviors so that they positively affect the Integrated Experience. For example, if staff respond quickly and positively when a client is utilizing positive behaviors to meet their needs, the staff behavior and attitudes will encourage continued positive behaviors and attitudes in the client. Better yet, when staff are able to anticipate the needs of their clients before Precipitating Factors occur, they can prevent the behavior overall. On the other hand, if staff do not plan well, or are not able to control their unproductive reactions, they may respond out of their own fear and anxiety in a negative or inappropriate manner which may escalate the behavior of the client.
Nonviolent Crisis Intervention® training and PBIS complement each other during a crisis because they allow us to look at behaviors through two lenses: the form (what) and the function (why). The CPI Crisis Development ModelSM helps us organize our thinking about the form of behavior (via the levels of the model) and PBIS helps us understand the function of behaviors. Three commonly identified functions of behavior are: escape, access, and sensory fulfillment. For example, if three clients run away, the form of the behavior is the same, but the functions might be different.
- Sally might run away because she is escaping the current situation that is overwhelming to her.
- Jane may run away because she wants to access the attention of staff who will chase after her.
- And Lisa may run away because she needs the sensory stimulation provided by physical movement.
All help us to understand the level that the client is in (Anxiety) and what we can do to provide a Supportive approach. Our Supportive approach would be different in each of the cases because the function of the behavior is different. For example, "Supportive" for Sally may mean reducing task demands so that the task is not so overwhelming. "Supportive" for Jane may mean providing attention on a regular basis so that she doesn't seek it through challenging behavior, and for Lisa may mean providing regular opportunities to exercise.
When we understand the function of behavior, it also helps us to understand how Precipitating Factors and staff responses affect behavior. PBIS refers to this as the ABCs of behavior:
A : Antecedents (The Precipitating Factors that trigger behavior)
B : Behavior (The observable behavior that follows the antecedent/Precipitating Factor)
C : Consequences (The natural consequences or staff responses that follow a behavior)
According to the ABCs of behavior, both the A and the C affect the client's use of behavior during a crisis and in the future (Crone & Horner, 2003).
A—Antecedents (Precipitating Factors that trigger behavior)
By recognizing antecedents to behavior, we as staff can reduce or eliminate the Precipitating Factors in the environment. Precipitating Factors are internal or external causes of acting-out behavior (CPI, 2005). Sometimes staff have little or no control of internal factors or what goes on outside of the organization, however, we do have some control over the environment at the organization. PBIS strategies help us remove the Precipitating Factors from the environment. For example, George, a new resident in an adult group home, was placed in bedroom #1 at intake. After a few nights, George was getting up and roaming around the group home and refused to go back to bed for hours, often laying on the couch and falling asleep there. As staff attempted to figure out what was keeping him from sleeping, they discovered that the furnace was under bedroom #1 and the sound of it turning on and off and running was keeping him awake. A quick bedroom change and George no longer roamed the house. Changes in the environment such as this can prevent the behavior from occurring in the future.
B—Behavior (The observable behavior that follows the antecedent/Precipitating Factor)
Another way to help an individual reduce reliance on challenging behaviors is to teach the person a new way to communicate or fulfill her needs in a way that is more conducive to the best interest of the Care, Welfare, Safety, and SecuritySM of everyone involved. For example, Mary, a resident of a longterm care facility, has recently broken three mirrors in her room from throwing her hairbrush at it. Mary has partial paralysis on her right side due to a stroke, and some days it is very difficult for her to fix her own hair. When frustrated she has started to throw things and scream for a staff member to come and do it for her. The staff have worked with Mary to simply use her call button if she is having a difficult time, and they will assist her. They have also made the time to stop by in the morning to ask how she is doing and see if she thinks she will need assistance that day. Through this process, Mary has learned to call for help before she is frustrated and that there is no need to throw things and scream to get the staff's attention. Another example, often found in clinic settings, might be a sign that states, "If you have been waiting longer than 15 minutes, please check with the receptionist." This gives permission and guidance to visitors to ask about their wait time in an appropriate manner and helps ease the anxiety of waiting and not knowing how much longer it will be. Skills such as these reduce a client's reliance on challenging behaviors.
C—Consequences (The natural consequences or staff responses that follow a behavior)
The consequences of behavior (staff responses) also affect the Integrated Experience. How we have responded to a behavior in the past will influence whether the individuals choose to use the new behavior or the old (challenging) behavior in the future. If they use the old behavior and still get what they want, why not use it again? If they use the new behavior and it more effectively and efficiently helps them get what they need, they are more likely to use the new behavior again in the future. For example, let's say that Tom has a history of hitting staff members when they assist him with hygiene skills. This was identified as an escape function caused by not understanding the task. In the past, staff would back off and allow him to skip the task. In this case, the previous staff response reinforced (maintained) Tom's hitting behaviors which continued for several months. In response, staff decided that a positive alternative skill would be to help Tom by teaching him hygiene skills in a step-by-step format and providing him with visual reminders that assist him in remembering. This built Tom's independence, and was safer for everyone because instead of physically assisting, staff could visually remind him by referring to the visual instructions. Now, when Tom refuses to do hygiene tasks, he is redirected to visual cues and offered positive reinforcement, which has been successful in reducing the hitting behaviors. In this case, the staff response increased the positive behavior and reduced the challenging behavior as well as improved the quality and independence in Tom's life. Furthermore, the environment (A) and staff responses (C) are less of a Precipitating Factor to the behavior. Overall, both the Integrated Experience and philosophy of PBS are focused on reducing behaviors that threaten the welfare and safety of everyone involved and increasing and supporting behaviors that contribute to a culture of Care, Welfare, Safety, and SecuritySM.
What can we do to integrate PBIS into Nonviolent Crisis Intervention® interventions? During the CPI COPING ModelSM (Postvention), we investigate alternative behaviors and negotiate a plan for the future. In developing such a plan, we should aim to address the three areas highlighted in PBIS:
- How we can modify the environment? (Take Precipitating Factors out of the environment.)
- How we can teach new skills that compete with the challenging behavior? ("Investigating" new options with the client.)
- How we can control staff and natural responses? (Being aware of how our responses affect the integrated experience and how the client will respond during crises in the future.)
(CPI, 2005; Horner & Carr, 1997; Horner et al., 2002)
In taking a closer look at modifying the environment, you might ask questions such as:
- When asked to perform an independent task, does the client have the information and tools necessary to complete the task?
- Is the environment over- or understimulating to this particular individual?
- Does the physical structure of the room and building increase the likelihood of success and assist in the development of behaviors and skills which we want the individual to have?
In investigating new skills regarding the challenging behavior, it is important to again consider the function of the behavior. Consider the following:
- If the function is to escape, think of teaching behaviors/skills like coping skills for anger, frustration, or overall overwhelming situations. Think of rewarding cooperation and compliance quickly and in a meaningful way to the client.
- If the function is to access, think of ways the individual can get what he or she is searching for in a positive way. For example, asking for help, asking for one-on-one time, asking for alone time, or taking a voluntary time out.
- If the function is to meet sensory needs, think about things like providing things that can be touched or squeezed, items the individual can wrap themselves in, opportunities to move around, opportunities to help choose lighting and noises present.
In considering how we can control staff and natural responses, you may want to take into consideration the following:
- Are staff inadvertently reinforcing challenging behavior by allowing access to the client's desired consequence through their use of challenging behavior?
- Are staff finding ways to rationally detach? If not, what are ways the team can support Rational Detachment for the challenging situations faced? Remember, their behavior communicates to the client. What message are they sending?
- Are staff providing consistent and quick positive reinforcement for the use of positive behavior? (Such as positive reinforcement schedules.)
- Is the team working together to support one another in the difficult moments? If not, how can we as a team support one another?
- Do we need to encourage staff consistency by providing detailed lists of appropriate and inappropriate staff responses that staff should use in response to specific behaviors?
A behavior support and intervention plan that considers all of these factors is an effective way to reduce challenging behavior and increase and support positive behaviors. Both Nonviolent Crisis Intervention® program strategies and Positive Behavioral Support strategies contribute greatly to the Integrated Experience of a crisis moment and our ongoing efforts to provide the best Care, Welfare, Safety, and SecuritySM to those we support.
Crisis Prevention Institute. (2005). Instructor manual for the Nonviolent Crisis Intervention® training program. Brookfield, WI: Author.
Crone, D., & Horner, R. (2003). Building Positive Behavior Support systems in schools: Functional Behavioral Assessment. New York: Guilford Press.
Horner, R. (2000). Positive Behavior Supports. Focus on autism and other developmental disabilities, 15 (2), 97-106.
Horner, R., & Carr, E. (1997). Behavioral support for students with severe disabilities: Functional Assessment and comprehensive intervention. Journal of Special Education, 31(1), 84-105.
Horner, R., Carr, E., Strain, P., Todd, A., & Reed, H. (2002). Problem behavior interventions for young children with autism: A research synthesis. Journal of Autism and Developmental Disorders, 32(5), 423-446.
Originally published in Journal of Safe Management of Disruptive and Assaultive Behavior, March 2006.