I presented a symposium on the Ethics of Behavior Support vs. Behavior Management at Malone University last week. It was well received, and there was good discussion on the power dynamics at play in the process of supporting versus managing the process of behaviour change.
One of the questions asked was about the power dynamics in this process. Who makes the decisions about when or why someone’s behaviour should be changed. A helpful model to understand how to answer this question is below:
Source: Scott HK, Jain A, Cogburn M. Behavior Modification. 2022 Jul 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29083709
When someone’s behaviour is only different, the power to choose to change these behaviours is entirely with the person with a behavior support framework. There simply is no reason to tell someone their different or odd or unusual behaviours should change. It is up to the person!
Likewise, behavior that is dysfunctional, that is, choices that get in the way of the person’s own goals in life, can only be changed at the request of the person. As is the case with behaviour that is different, people who know and care for the person can give them feedback about their behaviour, make suggestions, but at the end of the day, it is their choice.
When someone’s behaviour is causing others distress, the process of supporting behaviour change becomes more entangled in questions of ethics. Can we let someone engage in behaviour that is causing distress? It seems to me that we should do everything possible to support people to choose to change their behaviour so it does not cause others distress, and if we cannot, then we have a responsibility to the other people to support the process of behaviour support. This is best accomplished when there is a relationship built on a foundation of trust, caring, genuineness, and hope between the person and the individual(s) providing behaviour supports. There must also be a clear understanding that restrictive practices such as punishment will not be used.
The final area is behaviour which is dangerous. Here the lines become clearer. We cannot let someone hurt others, though there may be times when someone is harming themselves and the choice could be made not to intervene. For example, I supported a person who had an extensive history of sexual abuse beginning at age 4 until age 7, and as a result was tactilely defensive, she could not tolerate touch of any kind. Touching her in the kindest of ways to redirect her from scratching or pinching or biting would, in my opinion, cause more harm through re-traumatization than letting her harm herself. However, if she attempted to harm others, then the use of redirection or other restrictive practices may be needed.
In my work in Australia, I have been fortunate to work with teams of individuals who believe in this approach and have been able to completely eliminate the use of physical and mechanical restraint, and significantly reduce and in several cases eliminate the use of chemical restraint. In the case where chemical restraint is used, I have been able to develop "easy read” versions of the behaviour support plan so the individuals I am supporting can understand and participate in the discussions about how to maintain safety for all people.
The only way I can do my work is if the person I am supporting trusts me. Notice I have not used the word “client” here – in Old English, a client was a person under the protection of the landlord. When people talk about “my clients” there is the potential to shift back into a relationship where the providers of services have the power and their clients are under their protection. This institutional model has the potential to be misused and abused. We must instead develop relationships of trust, of caring, and be genuine or real or honest in all our discussions. When we do that, hope is born and behaviour changes.