A Compassionate Approach to Addressing Self-Injurious Behaviour Using Positive Systems Approach
- drbobcarey
- Mar 11
- 8 min read
Self-injurious behaviour (SIB) is unfortunately prevalent among individuals with developmental disabilities, though exact figures can vary widely depending on the specific disability and the population studied. Generally, it's estimated that anywhere from 10% to 17% of individuals with developmental disabilities exhibit some form of SIB.
The impact of SIB on both individuals and society is significant. For individuals, it can lead to physical harm, infections, and in severe cases, even life-threatening injuries. Psychologically, it may indicate underlying issues such as frustration, communication difficulties, or sensory sensitivities that the individual struggles to express in other ways. This can impact their quality of life and ability to engage with others and their environment.
On a societal level, the consequences include increased healthcare costs due to medical treatments for injuries, specialized care needs, and potentially reduced productivity if individuals are unable to participate fully in educational or work settings. Socially, it may lead to stigmatization and misunderstanding, affecting the integration and acceptance of individuals with developmental disabilities into communities.
Efforts to understand the causes of SIB and develop effective interventions are crucial not only for improving individual well-being but also for reducing the broader societal impacts of this challenging behaviour. Self-injurious behaviour (SIB) among individuals with developmental disabilities presents significant challenges for caregivers and professionals. Historically, interventions ranged from physical restraints to punitive measures, often infringing on the dignity and rights of those affected. In contrast, the Positive Systems Approach (PSA), as detailed by Dr. Bob Carey and Terry Kirkpatrick in their book "Managing Disruptive Behaviours with a Positive Systems Approach," offers a humane and effective alternative. This blog explores the evolution from past practices to the PSA methodology in addressing severe self-injurious behaviour.
Historical Treatments: A Reflection on Dehumanizing Practices
In the past, treatments for SIB often prioritized control over compassion, leading to methods now viewed as dehumanizing and abusive:
Physical Restraints and Isolation: Individuals exhibiting SIB were frequently subjected to mechanical restraints, such as straitjackets, or confined in isolation rooms, aiming to prevent harm but often resulting in psychological distress.
Aversive Conditioning: Techniques involving the application of unpleasant stimuli, like electric shocks, were employed to suppress self-injurious actions. Notably, the Judge Rotenberg Center utilized the Graduated Electronic Decelerator (GED), a device delivering skin shocks, which was condemned by the United Nations as a form of torture and eventually banned by the FDA in 2020.
Pharmacological Interventions: High doses of antipsychotic medications were administered to sedate individuals, often without addressing underlying causes of SIB, leading to significant side effects and diminished quality of life.
Insulin Shock Therapy and Electroconvulsive Therapy (ECT): Some practitioners applied insulin-induced comas and ECT to children with autism exhibiting SIB, methods now considered highly unethical.
Lobotomies: Surgical procedures severing connections in the brain were performed to control severe behaviours, resulting in irreversible impairments and loss of personal autonomy.
The Emergence of Positive Systems Approach (PSA)
Developed in the 1980’s by Dr. Bob Carey, PSA represents a paradigm shift from punitive measures to positive, systemic interventions. It emphasizes understanding the individual's environment, personal history, and the systemic factors contributing to behaviour. PSA focuses on creating supportive settings that promote well-being and reduce the occurrence of challenging behaviours.
Core Principles of PSA
Holistic Understanding: Recognize that behaviour is influenced by a combination of environmental, social, and individual factors. This comprehensive perspective allows for more effective intervention strategies.
Empowerment and Autonomy: Encourage individuals to participate in decision-making processes affecting their lives, fostering a sense of control and self-worth.
Positive Reinforcement: Focus on reinforcing desirable behaviours through rewards and recognition, rather than punishing undesirable ones.
Collaboration: Engage caregivers, family members, and professionals in a unified approach to support the individual, ensuring consistency and understanding across all interactions.
Skill Development: Provide opportunities for individuals to learn coping mechanisms and communication skills, reducing frustration and the likelihood of SIB.
Implementing PSA in Addressing Severe Self-Injurious Behaviour
Applying PSA involves several strategic steps:
Comprehensive Assessment: Conduct thorough evaluations to identify triggers, environmental factors, and personal history contributing to SIB.
Environmental Modification: Alter surroundings to minimize stressors and eliminate potential triggers, creating a safe and supportive environment.
Building Trusting Relationships: Develop strong, respectful bonds between caregivers and individuals, which are crucial for effective intervention.
Teaching Alternative Behaviours: Introduce and reinforce positive behaviours that serve the same function as the self-injurious actions, providing healthier outlets for expression.
Ongoing Monitoring and Adaptation: Regularly review and adjust strategies based on the individual's progress and changing needs, ensuring the approach remains effective and responsive.
Case Study: Addressing Severe Self-Injurious Behaviour Using the Positive Systems Approach
Background Information
David is a 26-year-old man with a moderate intellectual disability and limited verbal communication skills. He lives in a supported residential home with three other individuals and receives assistance from a team of caregivers. For several years, David exhibited frequent and intense head-banging behaviour, often striking his head against walls, tables, and the floor. This behaviour occurred multiple times a day, leading to severe bruising, swelling, and, on occasion, open wounds requiring medical intervention. Despite previous behavioural interventions, including the use of protective helmets and medication, the head-banging persisted and often escalated in stressful situations.
Comprehensive Assessment to Determine the Function of the Behaviour
A Positive Systems Approach (PSA) was implemented to understand and address David’s self-injurious behaviour effectively. The assessment process involved multiple components:
Functional Behaviour Analysis (FBA): Observations and data collection over six weeks revealed that David’s head-banging was most common in the following situations:
During transitions (e.g., moving from one activity to another)
When his requests were denied
In noisy or chaotic environments
When left alone for extended periods
Environmental Analysis: The assessment identified several contributing environmental factors:
Overstimulation in noisy settings led to increased distress.
Inconsistent responses from caregivers contributed to confusion and frustration.
Lack of a clear communication system made it difficult for David to express needs effectively.
Medical and Sensory Review: A thorough medical examination ruled out underlying health issues such as headaches, ear infections, or gastrointestinal discomfort. Additionally, a sensory assessment indicated that David sought deep pressure and vestibular stimulation, which could explain why the physical impact of head-banging provided temporary relief or sensory feedback.
Personal History Review: Interviews with family members and long-term caregivers revealed that David had a history of disrupted caregiving environments. Early in life, he was moved between multiple placements, which led to difficulties in forming stable relationships. This background suggested that his behaviour could be partly influenced by attachment difficulties and a lack of trust in caregivers.
Implementation of the Positive Systems Approach (PSA)
With a comprehensive understanding of the factors driving David’s behaviour, an individualized intervention plan was developed based on PSA principles. The following strategies were implemented:
Modifying the Environment to Reduce Triggers:
A structured daily routine with visual schedules was introduced to minimize anxiety around transitions.
Noise-reducing headphones were provided to help him cope with overstimulating environments.
A designated quiet space was set up where David could retreat when feeling overwhelmed.
Enhancing Communication Skills:
A Picture Exchange Communication System (PECS) was introduced, allowing David to request items, express emotions, and indicate when he needed a break.
Caregivers were trained to use simple, consistent language and visual prompts to improve communication.
Introducing Alternative Sensory Activities:
A weighted blanket and deep-pressure activities (e.g., firm hugs, compression vests) were used to provide sensory input in a safe manner.
Access to a therapy swing and other movement-based activities helped David fulfill his vestibular needs without resorting to head-banging.
Reinforcing Positive Behaviours:
Caregivers were instructed to provide immediate praise and tangible rewards (e.g., preferred snacks, access to favorite activities) when David used alternative strategies instead of engaging in self-injury.
A token system was implemented where David could earn points for using communication tools instead of engaging in head-banging.
Building Trusting Relationships:
A primary caregiver and core team model was introduced to provide David with a consistent, reliable person he could turn to for support.
Daily positive interactions, such as shared activities and predictable routines, helped him build trust and feel secure in his environment.
Systemic Changes Implemented Through PSA
Beyond individualized strategies, systemic changes were also crucial in ensuring lasting success:
Consistency:
A core team was created whereby all of David’s caregivers received standardized training on how to respond to David’s behaviour, ensuring uniform responses across different staff members and shifts.
Clear, documented protocols were established for transitions, sensory breaks, and reinforcement strategies.
Portability:
David’s PECS communication system and sensory tools were made portable so that he could use them in different environments, including community outings and family visits.
A small sensory kit, including noise-reducing headphones and a weighted lap pad, was always available to him.
Team Health:
Regular team meetings and debriefing sessions were held to ensure caregivers felt supported and aligned in their approach.
Burnout prevention strategies, such as rotating responsibilities and ensuring staff had access to training and mental health resources, were prioritized.
Intensity:
During the initial phase, high-intensity interventions (e.g., one-on-one coaching, real-time feedback for caregivers) were implemented to ensure rapid and effective application of strategies.
Over time, these supports were gradually reduced as David’s behaviour improved, allowing for more natural integration into his daily routine.
Significant and Enduring Improvements
Over the course of six months, the following improvements were observed:
Reduction in Head-Banging Frequency and Intensity: Head-banging episodes decreased from multiple times a day to fewer than twice per week. When they did occur, they were less intense and shorter in duration.
Increased Use of Communication Tools: David actively used his PECS system to request breaks, express frustration, and indicate sensory needs, reducing his reliance on self-injury as a communication method.
Improved Emotional Regulation: He demonstrated greater tolerance for transitions and challenging situations, often seeking his quiet space or engaging in sensory activities instead of resorting to head-banging.
Enhanced Social Engagement: With the development of trusting relationships, David became more receptive to caregiver interactions, engaging in shared activities and showing increased comfort in social settings.
The success of this intervention highlights the effectiveness of the Positive Systems Approach in addressing severe self-injurious behaviour. By conducting a thorough assessment to identify the root causes of David’s behaviour and implementing personalized, proactive strategies, caregivers were able to help him develop healthier coping mechanisms and improve his overall quality of life. This case underscores the importance of understanding behaviour within a systemic framework and focusing on positive, individualized support rather than punitive or restrictive measures.
Case Study #2: The Importance of Identifying the Root Causes: The Impact of Trauma in Contributing to Self-Injurious Behaviours
As described in more detail in our book (“Managing Disruptive Behaviours with a Positive Systems Approach”) we outlined the interesting case of "Jane," a 40-year-old woman with limited verbal skills who exhibited severe behavioural outbursts, including self-injurious behaviours, often when supported by male staff members. A thorough functional analysis and extensive interviews revealed a history of sexual abuse by a male farmhand during Jane's teenage years. This traumatic experience was the key to understanding her current behaviour.
Through PSA, several critical steps were taken:
Environmental Modification: Jane was moved to a living environment without male residents and was supported exclusively by female staff. This immediate change led to a significant reduction in her outbursts.
Coping and Communication Skills: Jane's support team focused on improving her ability to communicate her feelings and taught her coping mechanisms, such as deep breathing and positive self-talk. This helped her manage anxiety and reduce her self-injury and disruptive behaviours.
Building Trust: Once Jane settled into her new environment and developed a trusting relationship with her female support team, she became more verbal and capable of expressing her needs and feelings.
This case exemplifies the effectiveness of PSA in transforming lives by addressing the root causes of behaviour and implementing compassionate, individualized interventions.
Conclusion
The evolution from dehumanizing treatments to approaches like PSA signifies progress in supporting individuals with developmental disabilities. By focusing on systemic factors, personal empowerment, and positive reinforcement, PSA offers a compassionate and effective framework for addressing severe self-injurious behaviour, promoting dignity and enhancing quality of life.
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