- a guest post by Ian Hutchinson, autistic clinician – NHS children’s services, Cornwall
Thinking about practical humanistic models for supporting autistic people in distress, time for a paradigm shift?
Over recent years and in service provision ranging from education and social care to specialist clinical services there has been an increasing focus on PBS – Positive Behaviour Support. A structured approach informed by Operant Conditioning theory and more recently the process of Applied Behavioural Analysis. It is increasingly being cited as the approach that underpins service delivery in many sectors including within specialist NHS services especially those catering for autistic people.
Many of us who are autistic share a sense of disquiet regarding how behavioural approaches can be misused in order to attempt to change fundamental aspects of how we are and from my own experience I would cite clumsy attempts to reduce or eliminate ‘stimming’ behaviour that have caused greater levels of distress to the individual. Within this context this crude application of behavioural techniques appears to be driven more by an ‘ableist’ agenda than the need to understand difference and provide effective support.
Whilst most pragmatic individuals view behavioural approaches as effective in certain circumstances as part of a ‘tool kit’ of support – the tendency in certain quarters to see them as the gold standard for reducing vulnerable people’s distress is considered by many of us to be deeply flawed.
Positive Behaviour Support, with its focus on building on strengths and diversion, which references the principal of DRO – Differential Reinforcement of Other Behaviour, when applied with due consideration and as part of a suit a more holistic approach can be a really useful approach for supporting both distressed individuals and those supporting them. However, it can also result in formulaic, crude, and limited thinking related to how best to nurture and connect with vulnerable people.
Whilst it is heartening, especially within services for younger people, to see consideration of other models especially those related to trauma theory and sensory processing, the current tendency of services for vulnerable people to focus on behavioural approaches as the best method for helping with distressed and dysregulated states is viewed with concern by a growing number of people.
There is however cause for optimism with the gradual rise in prominence of other approaches, for example the work of Professor Andrew McDonald’s and the ‘Low Arousal’ approach that he has been refining over the past two decades. This provides a more humanistic model to supporting people in distress that reframes ‘challenging behaviour’ as distressed behaviour and shifts our focus from a narrow consideration of the individual to attention to the views, feelings, and actions of those around them.
In relation to autism there is a neat congruency here, as we know that attempts to change fundamental aspects of an autistic person’s way of thinking and experiencing the wold is fruitless and inhuman. Instead, the imperative should be changing as much of what goes on around them as possible including other people’s behaviour.
It would seem that a paradigm shift in relation to how we set about supporting people in crises may be in sight and for many of us this will not come a moment to soon.
Ian Hutchinson, 13th March 2021