When I first started out as a psychologist, fresh from my training in both clinical psychology (counseling) and applied behaviour analysis (ABA), I often found myself struggling to reconcile these two seemingly opposing approaches. Clinical psychology viewed the client as holding the answers within themselves, often unlocked through talking therapies like Cognitive Behavioural Therapy (CBT), which focuses on uncovering and addressing maladaptive thought patterns that influence emotions and behaviour. On the other hand, ABA treated the client more like a blank slate, focusing solely on observable behaviours and largely ignoring the underlying thoughts and feelings, as they were considered unmeasurable and irrelevant.
Early in my career, particularly in the field of developmental disabilities, the prevailing method was “behaviour modification,” a practical application of ABA. The focus was strictly on altering behaviour, with little to no regard for any deeper psychological factors that might be contributing to the behaviours being targeted. The reasoning was straightforward: if you can’t observe it, you can’t measure it, so why bother? For those interested in the historical context of ABA and the origins of the Positive Systems Approach in the 1980s and 1990s, I highly recommend our book, Managing Disruptive Behaviours through a Positive Systems Approach. Click below to see it on Amazon.
One of my first significant cases involved a young man named Paul (fictitious name and image above), who had been diagnosed with severe Autism Spectrum Disorder (ASD) at a very early age. Paul had virtually no verbal communication skills, relying instead on grunts and screams to express himself. These sounds were often more communicative than one might think! He lived with his elderly parents until he reached his teenage years, at which point his behaviour became too challenging for them to manage. Paul’s behaviour included frequent physical aggression, property destruction and self-injurious actions like hand-biting and head-banging.
Paul’s first placement after leaving his family home as a teenager was a group home in his community. Unfortunately, this placement quickly fell apart. The group home, which housed six other individuals with various behavioural issues, was simply too chaotic for Paul. The constant transitions, changes in routine, and rotating staff members made him increasingly dysregulated and manic. Eventually, he was deemed too challenging for a community setting and he was placed in a large institution for children and adolescents with developmental disabilities and dual diagnosis. Here, he was subjected to intensive behavioural programs, which included punitive measures such as mechanical restraint and a time-out room.
By the time Paul turned 18, Provincial regulations (Ontario) required that he be discharged from the children’s treatment facility and returned to a community setting. He was placed in another group home, this time with only three other housemates. However, he did not fare any better in this new setting. The staff turnover in the group home remained high due to Paul’s challenging behaviours, and his placement was once again in jeopardy. The community agency managing his care was philosophically opposed to the harsh behaviour modification techniques that had been recommended by the psychologist from the children’s facility where he had been discharged from. Despite this, however, they had no alternative strategies and were considering referring Paul for a placement within an adult institutional setting.
At this point, I had just started working as a psychologist in the newly established Community Services department of a large institution for adults. My role was to help community agencies prepare for the influx of people who would soon be discharged from institutions as part of the broader de-institutionalization movement in Ontario during the 1980s. We also worked to prevent new referrals to institutions by developing support plans for community agencies and providing staff training. Paul’s case was referred to our Community Services team in a last-ditch effort to maintain his community placement.
When I first visited Paul in his group home, I was immediately struck by the chaos. Paul was like a one-man wrecking ball, systematically destroying almost every unsecured piece of furniture in his environment. Staff members either fled from him or tried desperately to restrain him, with little success. Paul, who was about 19 years old, tall, and wiry, seemed to be in a constant state of manic agitation, screaming and bouncing off the walls for hours on end. His behaviour terrified his housemates and overwhelmed his staff, who were understandably traumatized.
The agency made it clear that they would not implement punitive behaviour modification techniques, and I wholeheartedly agreed. These methods not only clashed with my personal philosophy but also created significant risks when applied in an unsupervised environment with untrained staff. However, it was evident that we needed to come up with a drastic solution, especially as the de-institutionalization movement was gaining momentum, and soon there would be no institutional settings left for challenging cases like Paul’s.
It quickly became clear to me that the key to supporting Paul lay in creating an environment that was tailored to his unique needs. Although he was non-verbal, Paul communicated clearly through his behaviour, and we needed to listen to what he was telling us. We conducted a Functional Analysis of his behaviour in the group home, and it became apparent that his outbursts were often triggered by noise, excessive stimulation, transitions, authoritarian staff members, digestive issues, and sleep deprivation. His aggression and property destruction were ways of avoiding demands, while his self-injurious behaviour and manic episodes seemed to stem from frustration, stress, anxiety, and physical discomfort (we later discovered he was gluten and lactose intolerant).
To address these issues, I proposed an entirely different living environment for Paul—one that would accommodate his needs while also creating a safe space for him to learn more appropriate ways of communicating. The design of this new environment included a separate, detached residence for Paul on a quiet, 10-acre property. His separate living area was set up as a “Snoezelen room,” filled with stimulatory objects and activities he enjoyed, which he often used to self-calm. The residence could be isolated from the main house to prevent him from disrupting or frightening his housemates. It was constructed to be virtually indestructible, with reinforced walls, vinyl flooring, solid furniture bolted down, and a TV behind a plexiglass screen. His kitchen was tailored to his dietary needs, free from gluten and dairy.
Another key aspect of the plan was incorporating Paul’s love for animals. We began the process of acquiring a therapy dog for him, a shepherd crossbreed that would be specially trained over two years to help manage Paul’s disruptive behaviours. The dog would respond to Paul’s agitation by staying close to him or lying across his lap, providing tactile pressure that helped calm him down. Paul also responded well to wearing a weighted vest, which he could wear whenever he wanted and had a similar calming effect.
But perhaps the most crucial component of Paul’s support plan was the selection, recruitment, and training of his staff team. The first step was hiring a Case Manager/Primary Counselor, and there was one woman who stood out. She had worked with Paul in his previous group home and had demonstrated an immediate rapport with him. She remained calm in the face of his behavioural storms and had a natural ability to de-escalate him. She also encouraged Paul to use picture symbols or hand signs to communicate more effectively. She was the obvious choice to lead Paul’s support team. This case manager was involved in hiring the rest of the team, and we selected individuals who shared her calm, unflappable demeanor and had a genuine fondness for Paul. The agency secured adequate funding to ensure that Paul always had at least two staff members with him during waking hours. We also brought in a medical practitioner and psychiatrist to adjust his diet and medications as needed. Paul’s family played a vital role in the support team, providing insights into his likes and dislikes and helping us create a rich, stimulating environment that met his needs. His family also agreed to the “portable” nature of the support plan, visiting Paul in his new home rather than bringing him to stay with them. This consistency was crucial in maintaining the progress we were making.
We implemented written protocols for all interactions with Paul, guiding staff on how to avoid power struggles, redirect him when he showed signs of agitation, and reward him for de-escalation. There were many more elements to Paul’s support plan, far more than I can cover in this brief post, but this case was the foundation for what would later become the Positive Systems Approach, as outlined in our book.
I’m happy to report that Paul thrived in his new environment. His disruptive behaviours disappeared as he learned to communicate his needs more appropriately, and his dedicated support team, along with his therapy dog, became his biggest advocates and friends. This experience taught me a valuable lesson which led to the formal development of Positive Systems Approach – namely, when we meet people where they are and create environments that respect their needs and communication styles, we can unlock incredible potential.
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