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Introduction

Positive Behavior Support, PBS, is a broad approach for organizing the physical, social, educational, biomedical, and logistical supports needed to achieve basic lifestyle goals while reducing problem behaviors that pose barriers to these goals (Dunlap & Carr, 2007; Koegel, Koegel, & Dunlap, 1996). The PBS values emphasize a commitment to helping individuals achieve a quality of life that is defined by their personal choices. How people behave affects how they live and how they receive support guided by their preferences (Wheeler & Richey, 2010).

According to Wheeler and Richey, problem behaviors such as aggression, self-injury, disruption, pica, noncompliance, withdrawal, and disruption are a major barrier to the social, vocational, and physical success of each individual. PBS believes the elements of personal life depend at some level on our ability to behave competently.

Theory

Applied Behavior Analysis (ABA) emphasizes the applied study of socially relevant behaviors. It focuses on measurable and observable behaviors with precise measurements. Positive behavior supports is a refinement and extension of ABA, which stresses positive approaches to behavior change and seeks to enhance quality of life for the individual.

Positive behavior support is the theoretical model that we will use to construct our intervention plan. Based on Serena’s unique characteristics, we chose the Positive Behavior Support (PBS) approach because of the ample amount of evidence that supports it ability to change problem behaviors, which would work well with Serena’s diagnosis of borderline personality disorder and her self harming behaviors. Serena’s emotional outburst and self harming behavior results in dysfunction in her occupational performance, which is why this makes Senera a good candidate for PSB.

Using this theory, it will help Serena change her lifestyle in a direction that would improve her quality of life (Carr et al., 2002). Additionally, using PBS would render Serena’s problem behavior, which will help her achieve her goals in a socially acceptable manner, thus reducing or eliminating all together, episodes of emotional outburst and harming behavior (Carr et al., 2002).

Evidence

As of now, there are limited studies that have examined the link between positive behavior support (PBS) and symptom change specifically in borderline personality disorder (BPD). However, there is evidence to support PBS in reducing problem behaviors such as aggression and self-harm, which are two significant symptoms in individuals with BPD.

Tolisano, Sondik, & Dike (2017) conducted a study in which the PBS model was used to treat aggression in forensic settings. Through the use of ecological strategies, positive programming, focused support strategies and reactive strategies, the behavioral consultation team assisted patients in transitioning into the community through a means of reducing aggression, rate of restraint and seclusion, as well as reducing occurrence of recidivism.

One case study specifically included a female with severe self-injurious behaviors and a diagnosis of borderline personality disorder. Coping strategies such as self-soothing were encouraged as well as body-centered techniques to promote self-regulation. Active treatment data was collected over the course of six months and the data concluded a decline in self-harming behaviors as well as aggressive tendencies.

Case Study

Serena is a 35-year-old single Caucasian female. At age 21, Serena was already addicted to drugs and admitted to a mental health ward where she was diagnosed with borderline personality disorder. Since her release from the ward, Serena still battles with emotional instability and self-harm behaviors. When she feels stressed or has an emotional outburst she self-mutilates her skin. She works an office job that entails duties such as data collection, answering phone calls, and managing files. Serena stated she does not like her job due to poor relationships she has with coworkers. She said she easily becomes angry when people are not accepting of her ideas during meetings. Her coworkers frequently do not understand her unpredictable “snaps” or emotional outbursts because she appears ‘normal’ on the outside. To relieve her stress, Serena enjoys pampering herself but cannot afford it secondary to lost of work days because of her emotional outbursts.

Intervention Plan

Problem Statement

Serena’s emotional outbursts with her coworkers is negatively impacting her work performance.

Long Term Goals

1. Serena will report independently implementing 5 positive behavioral support strategies in a regular work day to manage challenging behaviors within 10 weeks.
2. Serena will demonstrate adaptive personal coping strategies when presented with an undesirable situation at work within 10 weeks.

Short Term Goals

1. Serena will role-play adaptive personal coping skills to maintain self-control when presented with an undesirable situation in the workplace within two weeks.
2. Serena will identify two negative coping mechanisms to engage in work within one week.
3. Serena will identify three positive coping mechanisms to engage in work within one week.

Intervention Format

Individual and group

Setting

Serena will meet with the occupational therapist and group once a week for one hour at the clinic.

Supplies

N/A

Agenda

• Educate Serena about PBS
• Train Serena on reinforcing good behavior
• Introduce the token economy (she can earn staff cards that include long lunch break, VIP parking spot, early release, sleep-in day, work from home day when exhibiting positive behaviors at work)
• Educate on replacement behavior
• Summary

Documentation

S: Serena reported that she is having problems at work and that she gets “so angry” because of the people at her work. Serena reported that “nobody likes her ideas.”

O: Serena engaged in a 30-minute positive behavior support education based session. Serena required 11 verbal cues to redirect her to the topics of discussing her anger and positive behavior support strategies. Serena applied positive behavior support strategies in a role play session to demonstrate her knowledge of the strategies. She required 3 gestural cues to complete the roleplay activity. Serena was able to verbalize why these strategies may help her in bettering her relationships with her co-workers.

A: Serena greatly benefited from positive behavior support for coping with anger. Serena shows impairments with coping strategies which interferes with her ability to engage in social participation at work. Positive behavior support benefited Serena by providing a motivational reward system that would provide Serena with incentive to change her angry outbursts. Serena has insight into her anger and understands how her quick angry snaps at work have negatively impacted her finances due to lost work days. Serena would benefit from future OT to apply additional positive behavioral support strategies.

P: Serena will attend occupational therapy once a week for 1 hour sessions. During the next session Serena will create 1 new positive behavioral support strategy to enhance her coping abilities in her work place and demonstrate the strategy to the therapist.

References

Tolisano, P., Sondik, T. M., & Dike, C. C. (n.d). A Positive Behavioral Approach for Aggression in Forensic Psychiatric Settings. Journal Of The American Academy Of Psychiatry And The Law, 45(1), 31-39.

Wheeler, J. J., & Richey, D. D. (2010). Behavior management: Principles and practices of positive behavior supports. Pearson.