On Alcohol/Substance Abuse: A positive Behavior Support perspective

One of the list-serves I regularly participate in had a discussion about how to address serious substance abuse and addictions from the perspective of Positive Behavior Support, when traumatic brain injury is also involved. A question came about appropriate replacement behavior and / reinforcers. I posted a response and got some very positive feedback on it, so I post it here as well:

I agree that NA/AA is helpful to many, though there are also many folks who are not amenable to the 12 step approach and/or the group process that is involved.
I have limited experience with individuals who have both brain injury and substance abuse issues, but I have observed that chronic substance abuse is often more of a negative reinforcement situation...that is, it is about escape from or avoidance of uncomfortable/intolerable emotions, memories and thoughts. In that sense it often begins as a form of self-medication, though it then may become a serious complicating challenge.

In such a situation, appropriate replacement behaviors would be those behaviors (for that individual) that might also help that person escape, manage or resolve the anxiety or negative emotions that they experience. 12 step programs and various forms of therapy may be useful in addressing the physical addiction and even treating some conditions such as underlying depression, trauma, social isolation, etc. However, I'm not sure that any therapeutic program itself should be viewed as an effective replacement behavior (other than very short term). Rather, it is a means to establish replacement behaviors.

Finding actual replacement behaviors will be more about tapping into the person's intrinsic motivational system and his/her strengths to identify and support life activities that are meaningful, that help manage emotional stress, and that lead to a sense of comfort, belonging and self-efficacy.

A healthy exercise regimen, meaningful social and recreational activities, activities that relax (yoga, meditation, relaxation techniques, biofeedback may help), and positive activities that are highly motivating to the individual may all serve as replacement behaviors that help to constructively manage emotional and cognitive stress over time. I believe that the most powerful replacement behaviors, as a rule, are those that fit the specific person (person centered) and that contribute to long term quality of life.

On Punishment and Negative Consequences

On Punishment and Negative Consequences

By George Rathbone, Allan Rathbone

While punishment is used throughout most cultures to influence behavior, the concept of punishment is more complex than most people understand. Traditional thinking often goes like this: if someone acts out, and they get punished for acting out, then that person is less likely to act out again. The problem is, there’s a lot that this perspective doesn’t take into account, such as the complexities of human interaction and the power dynamics that are involved.

It’s not hard to understand where traditional thinking about punishment and negative consequences comes from, it can be very intuitive. Negative consequences frequently change our behavior. For instance if we eat something rotten and get food poisoning, we will get sick and feel terrible. As a result, the next time we feel hungry, we probably won’t try to eat anything rotten. Many people think punishment is like that; if you make someone feel bad, then they won’t do it again.

However, being punished by a person is different from drinking spoiled milk in a few obvious ways, especially when that person is an authority figure. For one thing, you’re not going to feel angry at the milk for making you sick. You’re not going to feel like the milk insulted you, or that it was unfair to you. It probably wouldn’t even cross your mind to struggle with the milk until it learns to stop making you sick. You’re not going to even think about trying to seek revenge on the milk, beyond pouring it down the drain, and you’re not going to feel like the milk is limiting your freedom or trying to control your life. Of course, these are all thoughts we all may have when being punished by a person. You may respond to punishment by feeling badly about yourself (low self-esteem); you almost certainly will feel angry . You may have thoughts of retribution against the person who punishes you. These reactions are normal, and they often lead to worse behavior rather than better.

Often punishment seems to work quite quickly, as the behavior may immediately disappear. For that reason, it is often the first strategy used. However, sometimes that disappearance doesn't mean that the behavior is gone, it just means that the person is being more careful not to be caught.

The fact is that punishment and negative consequences do not deter behavior; it is the threat of the punishment that deters behavior. The actual delivery of punishment just makes the threat believable. Once negative consequences are actually delivered a few times, they tend to lose their deterrent effect. When a person is punished repeatedly for the same thing, the punishment is clearly not working as a deterrent. At that point the continued use of punishment is likely to make behaviors worse rather than better. Arguably one of the worst results of repetitive punishment is that it can lead to the person to repeatedly engage in the negative behaviors it is intended to deter., or even to escalate into more seriously challenging behaviors. The person may feel very badly about the himself for doing it, but he may also feel a powerful compulsion to continue the behaviors anyway.

Just the same, negative consequences can not always be avoided. In fact, the “normal” world is highly punitive, and learning to cope with negative consequences is an important part of normal development. There are times, especially in public, when someone misbehaves so badly that the only solution is to take him or her out of that environment, at least for a while. Likewise someone may be too upset to safely participate in a desired activity, or an item or privilege may need to be taken away because of safety concerns.

One important fact to understand is that the person delivering the consequences does not necessarily need to become a bad guy. Many people make the mistake of getting emotional and angry at the person who is misbehaving, but that can make the situation worse. Expressions of anger can make the person believe that you are punishing him because he has upset you, rather than because he has misbehaved and broken the rules. That can make them feel like the consequences are not about their breaking the rules, but about your dominance over them. In addition, it tells them that when they misbehave they can have the thrill of upsetting their caretaker. Through misbehavior they can, in a small way, control their caretaker. It is almost always a mistake to become emotional. No matter how irritated or upset you may feel, it is best not to be angry when you respond.

The key to asserting a sense of accountability at such times like is not to lose your empathy for the person you are caring for. It is better if the consequences for misbehavior are the only consequences that the person receives, and that the consequences be delivered in a compassionate manner. No anger is needed, and it can be detrimental if is part of the response. Generally it is most effective, once you and the person are both calm, to talk about the behavior that resulted in the negative consequence and to help the person figure out how the consequence can be avoided in the future. For some individuals, it may be better not to talk about the negative behavior at all and to focus instead only on what he or she should do next time in a similar situation.

Perhaps the most common reason given for using punishment and negative consequences is that people must be held accountable for their bad behavior in order for them to learn from it. However, holding someone accountable does not necessarily require this negative approach. Punishment is only one piece of instilling accountability, and not the most effective one. Arguably it is far more effective to hold someone accountable for maintaining positive behavior, something that can be accomplished through a positive response. Rewarding good behavior, even if it is simply by telling a person when they’re behaving well, is much better for enhancing self esteem, for promoting a good relationship with that person, and for shaping positive behavior that is best for everyone.

Our first posting: Development, Learning and Behavior

Please have patience with me as DSA (Developmental Support Associates, LLC) begins this new venture. This blog will be used to express our philosophies, beliefs and perspectives on how individuals who experience disability can be assisted to reach their potential and to lead rich full lives in the community. My first few postings will be somewhat impersonal: writings that I use in my teaching and training efforts.

The first post is about Positive Behavior Support philosophy and practice, an approach that goes significantly beyond the tools of behavior management, behavior modification and applied behavioral analysis. The underlying assumption is that behavior is intimately tied to the quality of life of the individual. Challenging behaviors are seen as a sign that some relatively basic needs and desires are not getting met appropriately, and there may be a variety of possible reasons for this.

Many people are far more disabled than they need to be. The costs of this situation can be very high, for the individual, for those who support the individual, and for the taxpayers who pay a great deal of money for often mediocre and/or ineffective support services in the public and private provider sectors.

Please feel free to comment, ask questions, send me resources to check out, etc. The site will be moderated to ensure that critical feedback is positive and that emotions are expressed in a constructive manner.

Positive Behavior Supports:

A Person-Centered Approach to Supporting

and Developing Appropriate Behaviors

ABILITY, DISABILITY & SUPPORT

While abilities differ with each individual, every individual can be said to possess certain abilities or strengths which allow the individual to interact constructively and productively within the environment. Every individual requires some degree of support in the environment in order to meet basic needs and desires. An individual who is able to meet his or her basic needs and desires with supports that are available in the local community or setting is considered “normal” or non-disabled for that setting. However, when an individual requires special supports which are not readily available in the community or setting, then that individual is considered “disabled”. From this perspective, disabilities reside not in an individual, but in the interaction between the individual and his or her environment.

Many people experience far more disability than they need to, because the environment emphasizes the lack of ability, rather than reduces it. An individual who requires a wheelchair for mobility is only disabled to the degree that the environment does not allow for wheelchair use. In a wheelchair friendly space such a person may be almost entirely independent, but in environment that is not wheelchair friendly that same person may be totally dependent on others for the most basic of activities.

Through the enhancement of native abilities and strengths, and with the provision of needed environmental and social supports, every individual may have the capacity to function as a productive and valued member of the community.

POSITIVE BEHAVIORAL SUPPORTS

The philosophy of positive behavioral supports is rooted in the concept that every behavior an individual exhibits serves a positive function for that individual, even when that behavior is considered unsafe or socially unacceptable. Understanding the function of a given behavior for an individual is therefore of utmost importance if that individual is to develop new behavioral strengths. The process of achieving such an understanding is referred to as functional assessment of behavior. For instance, one person may hit others in order to obtain attention; in such a case it will be necessary to help the individual find a more appropriate way of gaining the attention he or she desires. Another individual may exhibit the exact same behavior in order to communicate physical discomfort; in that case an appropriate method of addressing the physical discomfort would be desired.

While a positive behavioral support approach may use behavioral modification strategies, the behavioral support philosophy is quite different from that of traditional behavior modification. Traditional behavior modification philosophy views the individual as almost irrelevant to the behavior change process, whereas a behavior support philosophy views the individual as central to the process. Underlying the concept of positive behavioral support is the observation that when a person is able to meet his or her basic needs and desires, that person is likely to behave in a generally positive manner. Thus it may be necessary to understand an individual’s needs and desires in order to help that individual develop a safer or more acceptable manner of expressing them.

Behavioral supports can take many different forms, but they may be grouped into three overlapping basic categories:

1) Behavior Crisis Prevention

In general, these are support strategies that focus on preventing or reducing stress factors which lead to behavioral crisis. They target the physical and/or social environment and seek to protect the individual from certain types of environmental hazards, stimuli or stressors. These are sometimes referred to as “proactive” or preventative behavioral interventions, as they focus on preventing behavioral crises from occurring. The development of behavior prevention supports involves identifying the internal or environmental factors that are triggering behavioral crisis or unwanted behaviors. Such factors can include internal stimuli (such as medical or psychiatric issues), external factors (such as loud noise or other stimuli), activity factors (such as boredom or dislike of a particular task), social interaction factors (such as feeling teased, rushed or harassed), and skill factors(such as needing help but being unable to ask for it), etc.

2) Behavioral Crisis Management

Management supports are focused on minimizing both the escalation and the negative impact of unwanted behaviors on the individual and the social and physical environment. While behavior management strategies may be preventative, the concept of crisis management implies that the initial stages of behavioral crisis have already been observed. The focus of effective crisis management support is the safe and speedy resolution of crises with minimal use of intrusive or restrictive approaches.

3) Behavior Development/Skills Training

Behavior development supports are strategies focused on learning or strengthening the learning of behaviors which are safe, effective and appropriate for an individual to use in the effort to meet his or her needs. The focus is on the enhancement and development of an individual’s ability to tolerate, avoid or manage internal or environmental stressors that are difficult to avoid. Thus a person who can not tolerate noise may need help learning how to get away from it before a behavioral crisis occurs, or someone who acts out in order to get help may be taught a an alternative more acceptable way to ask for help.

George Rathbone, NCC, LCPC

Developmental Support Associates, LLC