PBS in Crisis Situations: Strategies for Positive Outcomes

What is Positive Behaviour Support (PBS)?

Positive behaviour support (PBS) is a person-centred approach developed to support people living with a learning disability, autism, mental health challenges and complex needs, co-created with the person and their support network. It brings positive outcomes for people who experience behaviour that challenges (known as challenging behaviour), which affects their day-to-day activities, relationships, and every aspect of their lives. Positive behaviour support focuses on understanding a person’s abilities, needs and preferences, aiming to improve a person’s life, its quality and supporting them in the activities and hobbies they love.

Children, young people, and adults who require complex care deserve humanised care and support in their own homes, fully supported by caring, understanding care teams. To properly implement positive behaviour support, first identify the root causes of the challenging behaviour, then develop a positive behavioural support plan that includes active, proactive, and reactive strategies. At Leaf Complex Care, we value hearing from our care teams about how the people we support feel their rights, choices and individuality are respected. Take a moment to download our first comprehensive Autism Guide for parents on how to provide the best possible home support for their autistic children.

What does PBS Mean in a Crisis?

In a crisis, Positive Behaviour Support means responding in a way that protects everyone’s immediate safety while using the least restrictive option available. Staff follow the person’s individual support plan, reduce demands and environmental pressure, communicate calmly, allow space and use known de-escalation strategies. Our PBS specialists who reduce restraint begin by understanding the person rather than reacting to the behaviour alone. They use the person’s individual support plan, reduce demands and environmental pressures, recognise early signs of distress, and use familiar communication, therapeutic, and de-escalation strategies before considering any restrictive intervention. Following any use of restraint, the team reflects on whether all proactive options were fully explored.

Grounded in PROACT-SCIPr-UK®, our approach focuses on creating capable environments where people feel safer, better understood and more able to express what they need before distress escalates. Once the person feels safe and has had time to recover, the team reviews what contributed to the crisis, whether early signs were missed and what support needs to change. This learning is used to strengthen proactive strategies, teach alternative skills, and reduce the likelihood that the same crisis and the need for restraint will recur.

What Are Proactive Strategies?

Proactive strategies are personalised approaches and techniques used before distress escalates into crisis. Based on an understanding of the person’s potential triggers and health and social needs, the main goals of the proactive strategies are to ease the integration of the behavioural plans into current life situations, encourage functionally alternative behaviours, and provide suitable support to prevent behaviours of concern.

Proactive strategies promote long-term change in behaviours when implemented correctly. Rather than waiting for behaviour to occur, proactive support aims to prevent avoidable distress and reduce the likelihood of the need for restrictive interventions. These proactive approaches aim to enhance the quality of a person’s life and reduce the occurrence of challenging behaviours. With the right support, proactive strategies may include:

• Support in finding alternate ways of communication to improve social outcomes
• Protecting safety by adapting the environment in which the person lives
• Including more daily activities supporting the preferences of the person
• Offering different choices for activities
• Clarifying routines and providing schedulers or timers to minimise escalating behaviours
• Increasing predictability
• Reducing restrictive practices

Can PBS Prevent Restraint?

PBS cannot prevent restraints, but can significantly reduce the likelihood that restraints will be needed once the causes of distress and early warning signs are identified. The purpose and focus of PBS are to make restraint the last resort, ensure the least restrictive response is used, and review every incident to understand what could prevent them from happening again.

PBS can help prevent restraint by identifying the underlying reasons for distress and supporting teams to try safer, less restrictive alternatives instead of rushing towards control. In this case, the PBS team analysed the young woman’s behaviour, reviewed records over several months and modelled supportive strategies during outings. She was then able to enjoy successful trips without the high levels of distress seen before and without being subjected to restraint or a restrictive travel setup.
– George Rickard, Restrictive Practice Lead and Specialist Practitioner in Therapeutic Approaches at Leaf Complex Care.

The Escalation Cycle and PBS

The escalation cycle describes how a person may move from feeling calm and regulated towards increasing distress, crisis and eventual recovery. It can help support teams recognise changes early and respond before the person reaches a point where they or others may be at risk.

The cycle should never be treated as a rigid sequence that looks the same for everyone, but to respect people’s human rights and different needs. Each person has their own triggers, early warning signs, communication style, coping strategies and recovery needs. Positive Behaviour Support uses assessment, observation and the knowledge of the person and those closest to them to develop an individual understanding of what escalation looks like for them.

The Escalation Cycle involves five stages:

Trigger

This is the first stage that marks the beginning of challenging behaviour escalation. A particular event, behaviour, or life situation may be a potential trigger, whether internal or external. Internal triggers may manifest as emotional fatigue and/or feeling unwell, while external triggers stem from an unstructured situation or a sudden change in routine. The first phase triggers one’s emotional response, causing feelings of stress and anxiety. Typical behaviour triggers include moments when a person feels overstimulated by loud noises or bright lights. This is the phase when personalised support and the right PBS approach are most needed to prevent any challenging behaviour.

PBS does not assume that a single event always elicits the same response. A person may cope with a situation on one day but find it overwhelming on another because of pain, poor sleep, anxiety or earlier experiences. Behavioural assessment therefore considers what happened before the behaviour, the wider circumstances and what may have made the person more vulnerable at that time.

Escalation

In the second phase, the person’s behaviour gradually escalates, often starting with mild signs of discomfort or distress. This is the phase when the person may become more vocal about their feelings in the moment, leading to behaviours such as fidgeting, raising their voice, and becoming more argumentative. Since each person is different, in some cases, people can become more socially withdrawn. In these moments, the support workers will speak in a calmer tone to de-escalate the situation with interventions they had been trained for.

In PBS plans, these are sometimes addressed through active strategies: personalised responses are used when the person begins to show signs of distress and may be at risk of further escalation. The purpose is not to force the person back into the original activity.

Specialists should respond to what the person needs in that moment. This might involve reducing demands, offering a break, changing the environment, giving more processing time, using familiar communication or offering a preferred activity.

Crisis

At the crisis point, distress may be at its highest, and there may be an immediate risk of harm. The person may have very limited capacity to process explanations, make choices or respond to usual support.

PBS does not disappear during a crisis. It guides staff to:

• remain calm and regulated
• protect dignity
• reduce unnecessary interaction
• follow the person’s agreed support plan
• use non-restrictive responses wherever possible
• avoid punishment, blame or confrontation
• protect the person and others from immediate harm
• use any restrictive intervention only as a last resort

Reactive strategies should be clearly described in the person’s PBS plan. Our practicioners focus on non-restrictive, reactive, and proactive strategies designed to protect dignity and bring the episode to a safe end. Where physical intervention is required to prevent serious harm, it should be the least restrictive option, proportionate to the risk and used for the shortest possible time. PBS should never treat restraint as the primary response or evidence that the person has “failed”.

De-escalation

As the person begins to overcome the peak of the crisis and starts to calm, care teams must maintain a calm atmosphere during this phase. In those vulnerable moments, they may still be physically and emotionally vulnerable. A sudden return to demands, questioning, or discussion about what happened can cause escalation to resume. The PBS plan and behavioural support provide autistic people or people living with a learning disability with person-centred care that enables them to process their feelings, subsequently following the person’s individual recovery preferences.

Signs of de-escalation might include slower breathing, reduced movement, softer communication, acceptance of support, or a return to a familiar activity. These signs will vary from person to person.

Stabilisation

The stabilisation phase of the escalation cycle is the stage in which people have calmed down but may still be emotionally charged or sensitive. It’s a time that requires a deep understanding, respect and compassion from those around. Recovery strategies acknowledge that the person has experienced significant stress and needs support to feel emotionally and physically safe again.

Stabilisation and recovery may include:

• quiet time
• sleep or rest
• a drink, snack or familiar activity
• contact with a trusted person
• reassurance
• reduced demands
• emotional or sensory regulation support
• medical checks where pain or injury may be present
• an opportunity to communicate about the experience later, in an accessible way.

The person should not be required to apologise, explain themselves immediately or take part in a formal debrief before they are ready. Overall, the stabilisation phase is a critical opportunity to address the root causes of the behaviour and to work closely with therapy teams to prevent future escalations.

Implementing Positive Reinforcement

Positive reinforcement is a way to increase the likelihood that a useful, safe, or meaningful behaviour will occur again. It involves providing something the person values immediately after the behaviour occurs. Within Positive Behaviour Support, reinforcement should not be used to control the person or secure compliance for the convenience of others. It should help the person develop communication, coping, independence and social skills that enable them to meet their needs more safely and improve their quality of life.

PBS uses functional assessment to explore what the behaviour communicates or achieves for the person. For example, a person may shout because it reliably causes a difficult demand to stop. Teaching them to request a break will only be effective if that request is recognised and the break is genuinely made available. Praise alone would not meet the same need. This is often called teaching a functionally equivalent alternative behaviour: a safer and more accessible behaviour that produces the same meaningful outcome as the original response.

Here are some strategies for implementing positive reinforcement in Positive Behaviour Support (PBS) during crisis situations:

1. Identify and understand triggers 
2. Develop a crisis and a PBS plan 
3. Use positive language and tone
4. Provide immediate reinforcement
5. Use high-value reinforcers
6. Monitor and adjust strategies
7. Collaborate with support teams
8. Always focus on safety

Positive Outcomes with PBS

Positive behaviour support focuses on enhancing a person’s quality of life by promoting skills, independence, social inclusion and effective support. Also, PBS helps people engage more practically in activities they enjoy and interact more positively with others. One of the primary outcomes of PBS is the reduction of behaviours of concern and fewer crises. By identifying the underlying causes of these behaviours and implementing proactive strategies, positive behaviour support can help people learn more adaptive ways of responding to their environment.

The comprehensive approach teaches people new skills and strategies to meet their needs and promotes their independence, enabling them to become more autonomous. Through positive behaviour support, people learn social skills, such as communication, problem-solving, and conflict resolution. They are more likely to engage in meaningful activities as the challenging behaviour decreases. This can lead to increased participation in work, school, and community settings, ultimately improving their overall quality of life.

The approach promotes long-term success and helps people achieve positive outcomes when making decisions about how to be supported and live their best lives. 

Take a moment to watch Hayden’s care journey and the additional support our clinicians provided so he could live his best life. 

What is a PBS Plan?

A Positive Behaviour Support plan is a personalised, practical guide that explains how to support a person well, reduce distress and improve their quality of life. It is based on an understanding of the person’s communication, health, history, environment, preferences, strengths, potential triggers and the possible function of behaviours of concern.

The plan usually sets out proactive strategies for everyday support, early responses when distress begins, least-restrictive guidance for crisis situations and recovery support afterwards. It may also include communication approaches, environmental adaptations, skills teaching and agreed ways to monitor progress. A PBS plan should be co-produced with the person and those who know them well, and reviewed regularly as their needs and circumstances change.

Where Can it Be Used, and Who Should Use it?

The PBS plan is commonly used across all settings where the person spends their time, such as at home, in the community, at school or college, when visiting a family member’s home, or when going on holiday. The care team supporting the person must follow the positive behaviour plan, using proactive strategies and person-centred approaches.

It’s beneficial for caregivers of children or adults to observe what strategies are helpful or ineffective, allowing them to adjust or change approaches as needed. A positive behaviour support plan is designed for people who frequently experience behaviour that challenges and significantly impacts their lives. For instance, it might lead to exclusion from environments such as schools, day centres, or community activities like swimming. A PBS plan can be created and applied at any stage of life and help people integrate into society. The sooner challenging behaviour is understood and strategies are implemented to reduce it, the more advantageous it is for the person and their caregivers.

PBS Support with Leaf Complex Care

At Leaf Complex Care, Positive Behaviour Support is about understanding what sits beneath distress and creating the right conditions for people to feel safer, communicate more effectively and have greater control over their lives. Our in-house PBS practitioners work alongside families, support workers and the wider therapy team to develop proactive, person-centred support that reduces crisis, strengthens everyday skills and challenges unnecessary restrictions.

The impact can be significant.

In one of our recent six-month reviews, our care teams reduced physical interventions by more than 75%, from 40 recorded incidents in the first two months to just 9 in the final two months. PRN medication also reduced from 15 administrations to 1 across the same period. These outcomes show what is possible when support is consistent, trauma-informed and focused not on controlling behaviour, but on improving quality of life.

To learn more about how we can help you, contact us today or visit one of our offices in Bristol, the South East, the Midlands and Somerset.