Principles and Practice of Positive Behaviour Supports Workshop 2 Presented by the Psychology Department and the Open Training College
Any Questions So Far? § Content ? § Assessment ? § Online ? 2
Table Quiz on Policies 3
Workshop Objectives Today’s workshop looks at the policies that underpin person centredness and positive behaviour supports within SMH. It is important to be clear on these policies. If you are unclear about your role in relation to these policies, please talk to your line manager. The policies relate to your assessment for this course. Person Centred Planning Policy & Positive behaviour Supports Policy 4
Person Centred Planning in SMH § A new system for PCP in place § It fully replaces the old ‘IP’ system § It incorporates the Wellbeing Outcome Review process § COSAN (where it is in place in Local Centres) is now part of the Person Centred Plan. 5
All service users will have a Person Centred Plan. It will incorporate what is important TO and important FOR the person. 6
Policy of SMH: Person Centred Planning Staff in St. Michael’s House have a job. Their job is to help you to be the boss of your life. Their job is to support you to live your best life. Living your best life means that: § You spend time with people you like. § You do things that make you happy. § You get a job if you want one. § You go to college if you want. § You are a part of your community and are respected. St. Michael’s House knows that every person is different. What you want for your life is different to what your friends want for their life. 7
Policy of SMH: Person Centred Planning Staff in St. Michael’s House need to find out what you want to do in your life/ what your best life looks like. They need to find out what supports you need to get what you want. They will find out by talking to you and your family and friends. They will help you to make a plan to get your best life. This is called person centred planning. Person centred planning gets everyone to work together as a team. You are the most important person on your team. You are the boss. You decide who you want on your team to support you. Everyone works together to support you to get your best life. 8
Important information can be found in: § Communication passport § Old IP meetings § COSAN reviews § Wellbeing Outcome Reviews § ICM Minutes § Clinical guidelines § Support plans/ Care plans 9
Hierarchy of Outcomes Aspirational Outcomes Important to me Wellbeing Outcomes Emotional Physical Social Environment Communication Core Outcomes Rights and Safety 10
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Positive Behaviour Support An Organisational Approach within St. Michael’s House
Format of the Policy Section 1: General Policy Framework Section 2: Wellbeing § All service users have personal plan with wellbeing outcomes § If difficulties arise, review wellbeing and put supports in place Section 3: Challenging Behaviour § If difficulties continue a Multi-Element Person Centred Support Plan is devised (M-E Plan) § Based on MDT and functional assessment § Proactive and reactive strategies – no restrictive practices Section 4: Behaviour that poses significant challenge § If difficulties still continue an Enhanced ME plan is devised § Specialist Individualised MDT Support Appendices 1 -11 § Working documents, can be updated by steering group 13
Appendices 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Flow Chart Application of the Policy to Children Roles & Responsibilities Procedures of the Positive Approaches Monitoring Group Staff Support Framework Education and Development for Staff, Parents, Families, Service Users Service User Support Wellbeing Outcome Review M-E Support Plan Critical Incident Review process Risk Management Recording Forms 14
Positive Behaviour Support in the Context of SMH St. Michael’s House developed the Positive Behaviour Support Policy consistent with the current best practice in Positive Behavioural Support. St. Michael’s House views challenging behaviour as a reflection of poor wellbeing and as the product of the interaction between individual factors, and the circumstances in which people live, work and learn. All people who display behaviours that challenge in our service will have a Multi-Element Person Centred Behaviour Support Plan (ME Plan) based on a multidisciplinary assessment and ongoing 15 support.
Positive Behaviour Support Policy SMH 1. To provide a positive approach to behaviours of concern that can lead to distress and significantly interfere with the quality of life of Service Users themselves and those who live with and care for them. 2. To ensure that the necessary supports are available to enable Service Users to make positive behavioural choices, thereby reducing incidents of Challenging Behaviour. 3. To ensure that all interventions used to support Service Users respect their dignity and rights, and are in accordance with evidence based Best Practice. 16
Positive Behaviour Support Policy § Focuses on preventing challenging behaviours from occurring § Uses positive methods to generate new and different behaviours • changing the environment • improving the person’s lifestyle • avoiding the use of punishment/consequences 17
Principles of Positive Behaviour Support Policy § Reflect the individual needs and choices of Service Users § Support individuals to develop meaningful relationships, to make a valued contribution and become active members of their community 18
Principles of Positive Behaviour Support Policy § Empower people to make choices about where they live, learn, work and socialise § Advocate for the improvement and development of services § Provide interventions that are in line with evidence based * Best Practice 19
Section 2: A Person’s Wellbeing How we behave is reflective of our wellbeing which is defined as: “a state which enables an individual to function in society and meet the ordinary demands of everyday life. “ (Mental Health Foundation) 20
Poor Wellbeing St. Michael’s House views challenging behaviour as a reflection of poor wellbeing. Behaving in ways that are challenging, reflects an individual’s attempt to meet their needs, cope with frustrations and emotion in their life. (Clements and Zarkowska, 2000) 21
Social Commun ication Physical Wellbeing Outcome Review Emotion al Environment 22
Emotional Wellbeing Social Comm unicatio n Emotio -nal Physic al Enviro n-ment How the person feels How the person expresses their emotions and how others recognise their emotional states What’s important to the person in terms of likes and dislikes The person’s mental health 23
Physical Wellbeing Physical health Diet Sleep pattern Degree of physical independence Management of pain Management of health conditions Intimate care Manual handling FEDS policy Social Comm unicatio n Emotio -nal Physic al Enviro n-ment 24
Social Wellbeing Social Comm unicatio n Important relationships Engagement in meaningful activities Physic al Community Emotio -nal Spiritual beliefs Enviro n-ment 25
Environment How do physical environments impact on the person? Does the person experience sensory difficulties that affect their wellbeing? Environmental choice and control Transport Social Comm unicatio n Emotio -nal Physic al Enviro n-ment 26
Communication Social Comm unicatio n Emotio -nal Have my communication skills been assessed? Physic al How is the environment adapted for me? Not the Communications Policy Enviro n-ment 27
Wellbeing Outcome Review Meetings: Purpose To gather information from: § All about Me - Important to me § Assessment of Need – Important For Me § To Agree actions to progress goals and support plans § To create My Plan 28
Wellbeing Outcome Review Meetings: Purpose 1. Must be accessible to the person 2. Multi- disciplinary 3. Annual process 4. Involves thee person and their families (as appropriate) 5. Progress on actions is recorded and reviewed 29
Section 3: Challenging Behaviour If after the wellbeing outcomes have been reviewed and the agreed actions have been implemented anddifficulties still exist, then a multi element behaviour support plan (M-E Plan) is devised. 30
Multi-Element Support Plans 31
Goals of PBS To support individuals to: § Enjoy life § Be as independent as possible § Change their lifestyle and live a normal life § Overcome problem behaviour 32
Positive Behaviour Support Policy § Focuses on preventing challenging behaviours from occurring § Uses positive methods to generate new and different behaviours • changing the environment • improving the person’s lifestyle • avoiding the use of punishment 33
Multi-Element Support Plans § The development of strategies to prevent challenging behaviour § Teaching the person to communicate the function of their behaviour in a better way and building functional and meaningful life skills 34
Multi-Element Support Plans § Interventions that reinforce appropriate behaviour § Strategies for responding to incidents of challenging behaviour in terms of minimising incidents from escalating and maintaining safety 35
Multi-Element Support Plan Components 36
The plan is most effective when the environment the person is in supports each of the pillars. On viewing the following slides think about your practices and how you provide a supportive environment for positive behaviour supports. 37
Challenging behaviour cannot be addressed in a problem environment. (Reid et al. , 2004) 38
Importance of Environments The environment affects: § A person’s daily enjoyment § Learning and using important life skills § Whether challenging behaviour will occur (Reid et al. , 2004) 39
Important Things to Look for in the Environment § Interaction style § Environmental issues (Remember external factors as covered in workshop 1) § Meaningful and enjoyable activities suited to person’s needs § Choice § Predictability § Normalcy (Normality) 40
Create Supportive Environments § Create more supportive environments rather than trying to change the individual § Increase understanding and learning § Provide more predictability, visual structure and clarity to help calm and organise § Increase independence § Reduce probability of behavioural difficulties 41
Relationships and Interaction Style: Keys to Building Rapport § Spend time with the person and get to know them § Associate yourself with a wide variety of things that the person likes and values § Provide these preferred things for ‘free’ and share time with the person 42
Predictability ing go What a m I go ing to d next? I o m ? t a ow How o. I a n d h long rk W do will i wo t tak a to uch e? ke m do? ta How long do I ha to ow to t ve to H e e wait? av Ig h do What do n I get for he ? working? W ak re b When do I get it? 4 3
Visual Supports 44
Why use Visual Supports? Structure § To show what is happening, where and when § Help with difficulties planning, anticipating, and ‘knowing’ what is happening § Decrease levels of anxiety by providing a visual representation of structure 45
Why use Visual Supports? Structure § Showing individuals what is expected and when § Increase motivation to engage by reminding about positive events that are scheduled (‘First-Then’) § Can help ease transitions (difficulties attending) § Decreases reliance on verbal prompts over time 46
Creating more predictable and clear environments Presenting information in a visual form: § Helps establish and maintain attention § Gives information in a form the person can interpret § Clarify verbal information 47
§ Provides a concrete way to teach concepts such as time, sequence § Gives the structure to understand accept change § Supports transitions between activities or locations 48
Benefits of a more visual environment Consistent routines and visual instructions can help individuals to compensate for difficulties with distractibility, planning, sequencing, and organisation. Being able to predict the activities of the day gives the individual a sense of control, security and independence. 49
Question to consider before you create a schedule Who is it for? How will it give a perspective of time? What will it look like? How big does it need to be? Where will it be located? How mobile will it be? How do you use it? 50
Individualisation It may be necessary to adapt schedules to individual needs: § Consider how concrete or abstract the symbols should be § How can the individual use/manipulate the schedule? § Is the schedule stationary/portable? § Where should the schedule be place? § How much information should it contain? 51
How to Use the Schedule § Consider how to introduce the schedule to the person (e. g. , bring the schedule to the person or bring the person to the schedule) § Develop a verbal routine around the schedule to match the individual § Support the person to actually manipulate the schedule • Looking at the picture • Removing the picture • Using the finish box § Introduce a card for checking the schedule 52
Types of Individual Schedules 53
Types of Indiviudal Schedules 54
Objects of Reference 55
Adapting the Physical Environment 56
The Physical Environment § How we set up and organise the person’s physical space can have an impact on behaviour § Spaces associated with certain activities § Within those spaces how do we organise furniture, materials etc § Minimising visual and auditory distractions • Limiting the visual clutter in the environment • Covering visually distracting equipment • Storage • Developing areas for specific activities 57
Setting Up Tasks/Activities § How do we organise and present materials in a manner that is clear and understandable? § The work system • • • What am I doing? What work/tasks must be done? How much must I do? When will I be finished? What must I do then? 58
Setting Up Tasks/Activities How can we organise materials/information to reduce sensory input and information? § Using containers to organise information § Limit the work area § Provide visual cues 59
Visual Structure Visual Organization: § Organizing materials and space to modulate the sensory input 60
Breaking Tasks Down 61
Something New – The Art of Activity Sampling 62
Activity Sampling: Experience Something New § Sit down with another person and other individuals to brainstorm new activities. Generate a list of 20 activities! § Once the time is up, pick 3 or 4 items that you will then select and try out. Plan how you will introduce the items, activities with the person § For each new activity, record the person's reaction and make a note of how long they spent engaged in the activity 63
Waiting Skills 64
Wait a Minute! 65
Waiting § Waiting can be very difficult for many individuals as they may have low tolerance for delays in getting what they want § Difficulties understanding the concept of time and knowing how long they will be waiting for. What does ‘soon’, ‘wait a minute’, ‘later’ mean? ? 66
Visual Cues for Waiting § Visual cues such as cards and timers can help the person to more clearly understand the concept of waiting § It can also be useful to provide the person with a distractor while they are waiting e. g. , count, look at a book etc. 67
Supports to Help with Time 68
Choice 69
Importance of Choice § By allowing individuals to make choices we can promote independence § Choice gives an individual a greater sense of control over what they do and how they spend their time § Individuals may be more likely to participate and enjoy activities when they have more choice and this can also promote learning 70
Choice’s Ingredients Preference Opportunity Control 71
Choice Boards and Menus § Incorporate choice as part of the visual schedule § Support the person to have a greater sense of choice and control § Give the opportunity to teach requesting behaviours 72
Incorporate Choice Boards into Daily Routines 73
Teaching Functional Skills 74
Guidelines on Deciding What to Teach § Skills that someone else would have to do for the person if the person could not do the activity § Skills the person could use as part of their everyday routine (Reid et al. , 2004) 75
Guidelines on Deciding What to Teach Skills enable the person to access ageappropriate activities Skills to enable the person communicate what they want (Reid et al. , 2004) 76
Engagement § Every moment is a teachable moment § Little and often – remove steps if they are difficult § Graded assistance to ensure success § What can I do now to help the person engage § Every moment is a teachable moment § Little and often – remove steps if they are difficult § Graded assistance to ensure success § What parts can they do § § Low demand, easy Maximise choice and control 77
Engagement Different levels of engagement for each individual: § Doing the whole activity § Doing part of the task § Continuous through the task § Dipping in and out of the task § Taking the lead role § Joining in as a participant With assistance individuals can participate. 78
Develop Competing Behaviour Model (Adapted from O’Neill et al. , 1997) Setting Event Tired Desired Behaviour Ask for break Antecedent Academic task presented Behaviour Hand biting Consequence Escape task Touch Break Card Replacement Behaviour 7 9
Direct Interventions 80
Interventions that increase the likelihood of adaptive behaviour and improve well being § § Emotional support Social networks support Specialist interventions Short term change interventions 81
Reactive Strategies 82
Reactive Strategies • Low arousal strategies • Break away techniques • Post – incident supports § Development of strategies on how to respond to incidents of challenging behaviour § Guided by policy and training § Need to include plan for what to do post -incident § Plan should include analysis and review 83
Section 4: Behaviour that Poses Significant Challenge If the behaviour provides significant challenges, an enhanced approach may be adopted. The behaviour may be so extreme that a person’s placement has broken down. This approach includes development of an Enhanced Multi. Element Behaviour Support Plan § § MDT appointed by the Regional Director with a team leader The Team will be given terms of reference by the Regional Director and a specific time frame. Specialist respite provision may be required for the period of assessment The team may recommend specific interventions and/or service developments 84
Organisational Issues 85
Reporting Incidents § Staff need to be aware of the need to report all incidents of challenging behaviour to the appropriate people using the appropriate forms § Reports should be factual and objective account of the incident § Reports need to be completed soon after the incident has occurred to ensure that all information is recorded 86
Critical Incident Review When there has been a significant incident of behaviour that is challenging or an individual Service User has presented with a new behaviour a critical incident review process should be completed. The person in charge leads this process in collaboration with the staff involved/ relevant key workers. The purpose of the Critical Incident Review process is to learn from these incidents and is not about apportioning blame. :
Critical Incident Review The process includes: A description of the incident How it was managed – § What went well? § Did people know what to do? § What could be improved? Exploring the impact of the incident on staff / service users / others Recommendations for future – e. g. , does PBS plan need to be reviewed? Is more training needed? Are supports needed?
Support for Staff § § Sometimes following an incident of behaviour that challenges, staff may need emotional support. Staff have access to increasing levels of support as required, initially internal to the organization and subsequently external. They will be supported to access this by their management system and the HR department. Single-session interventions (often referred to as debriefing) that focus on the traumatic incident are not recommended. Employee Assistance Programme (EAP) offers confidential support to all staff at all times. 89
Tiered Support As outlined in Appendix 5 in PBS Policy Stage 1 – Immediate Support: Staff Member indicates that they require support/Head of Unit recognises that a staff member requires support - Head of Unit, Unit Clinician and/or work colleague offers immediate support to staff member. Stage 2 – Designated Support Team: Head of Unit makes contact with support team co-ordinator [Currently Head of Psychology] who nominates a support person for the individual/staff team. Stage 3 – Specialist support: referral made to specialist psychotherapeutic support or other appropriate service. EAP – Available to staff at any time in the process. 90
Online 2 looks at assessment, of both the behaviour, how do we do it and why; and assessment of the person’s life at the moment through the 6 Windows. As usual, any questions/issues please email your tutor. 91
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