The Journal of Forensic Psychiatry & Psychology, 2018

https://doi.org/10.1080/14789949.2018.1459785

An evaluation of the effectiveness of positive

behavioural support within a medium secure mental
health forensic service
Bronwen E. Daviesa, Kathy Lowea, Sara Morgana, Hannah John-Evansa and
Julie Fitoussib
a
Mental Health and Learning Disabilities Delivery Unit, Glanrhyd Hospital, Bridgend, UK; bSchool
of Psychology, Cardiff University, UK

ABSTRACT
A number of recent influential reports recommend the use of proactive and
preventative approaches such as Positive Behavioural Support (PBS) in the
management of challenging behaviours. Although evidence supporting the use
of PBS is mainly drawn from studies of learning disability and child populations,
it is recognised that PBS could have a much wider utility. In this study, PBS was
implemented in a medium secure forensic mental health service, a novel context.
Impact was evaluated using an adapted version of the Checklist of Challenging
Behaviour at baseline and then at 3 monthly intervals for a year. Significant
reductions were observed in aggression frequency, management difficulty and
severity and other challenging behaviour frequency and management difficulty.
Reductions in challenging behaviour were still evident after six months for the
full group and twelve months for the sub-group with the exception of other
challenging behaviour management difficulty. In contrast, no such significant
differences were found for a control group. This study indicated that PBS was an
effective intervention in the management of challenging behaviour in this forensic
mental health context.

ARTICLE HISTORY  Received 30 March 2017; Accepted 8 March 2018

KEYWORDS  Positive behavioural support (PBS); forensic mental health; challenging behaviour;
mentally ill offenders; evaluation; efficacy

Introduction
Within the NHS, incidents of challenging behaviour are recognised as a sig-
nificant problem and are often underreported (NHS Protect, 2014). In terms
of violence and aggression towards others, more than 60,000 incidents were
reported against all types of NHS staff across the UK between 2012–2013, of

CONTACT  Bronwen E. Davies  bronwendavies.pbs@gmail.com

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2   B. E. DAVIES ET AL.

these, 43,699 were in mental health or learning disability settings (NHS Protect,
2014). A survey of aggression and violence within a UK 207-bed forensic men-
tal health care provider found that, over a 16-month period, a total of 3,133
incidents were recorded involving 49.3% of the service users, 68.2% of these
incidents were directed towards others, whilst 31.8% were self-harm (Dickens,
Picchioni, & Long, 2013). Within this study patients showed a broad range of
behaviours including verbal aggression, physical aggression, property destruc-
tion, inappropriate sexual behaviour and self-harm.
As result of high levels of challenging behaviour within these contexts, pre-
vention, de-escalation and resolution of such incidents becomes a key task
for staff (Pulsford et al., 2013). Historically, staff working in inpatient settings
have utilised ‘traditional methods’ to manage challenging behaviour which
include restraint, seclusion and sedative medication (Kynoch, Wu, & Chang,
2011; Mason & Chandley, 1999). However, there has been growing evidence
that questions the effectiveness of such methods (See Duxbury, 2002) and even
suggest that they may be ‘counter-therapeutic’ (Riahi, Thomson, & Duxbury,
2016). These traditional approaches have been heavily criticised for being
aversive, unethical and creating only short-lived changes (Allen, James, Evans,
Hawkins, & Jenkins, 2005; Mind, 2013). As such, there have been various guide-
lines published within the UK from multiple sources (Department of Health,
2014; MIND for Better Mental Health, 2013, 2015; National Institute for Health
& Care Excellence, 2015a, 2015b; National Offenders Management Services
(NOMS), 2013; NHS Protect, 2014; Royal College of Nursing, 2013; Skills for Care
& Skills for Health, 2014) which all advocate a shift towards models which are
proactive and preventative in their management of challenging behaviour,
for vulnerable people within multiple contexts, such as Positive Behavioural
Support (PBS). Common amongst these documents are recommendations that
services should:

• Minimise the use of restrictive practices, ensuring they are used only as a
last resort.
• Gain an understanding of service users’ behaviours through functional
assessment.
• Work in a person centred way that promotes service users’ quality of life.
• Involve service users in all aspects of their care.
• During crisis, promote positive relationships between services, the people
they support and their families.
• Support people to balance safety with freedom of choice.
• Develop support plans focusing on preventing behaviours occurring in the
first place (primary prevention), de-escalating difficult situations (second-
ary prevention) and safely managing behaviours when they occur (crisis
management).
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY   3

Within this political context the use of PBS has been growing steadily in pop-
ularity. The PBS model has been implemented for a number of years, primarily
with children in the United States of America and people with an intellectual
impairment in the UK. More recently, its utility in the support of individuals
with behaviours that challenge has been recognised in a wider range of con-
texts. PBS is a values-led, multicomponent behavioural management framework
(Department of Health, 2014). Gore et al. (2013) identified that PBS encompassed
the following:
(a) developing an understanding of the challenging behaviour displayed by an
individual, based on an assessment of the social and physical environment and
broader context within which it occurs; (b) with the inclusion of stakeholder per-
spectives and involvement; (c) using this understanding to develop, implement
and evaluate the effectiveness of a personalised and enduring system of support;
and (d) that enhances quality of life outcomes for the focal person and other
stakeholders. (Gore et al., 2013, p. 15)
The PBS approach aims to improve individuals’ quality of life by incorporat-
ing a person centred approach, compiling personalised interventions through
comprehensive PBS plans and teaching individuals adaptive behaviours to
replace the challenging behaviours, and all in a non-punitive way (LaVigna
& Willis, 2012). Reduction in challenging behaviour occurs as a by-product of
improved quality of life rather than being the focus of the plan (Allen et al., 2005).
Moreover, basing PBS interventions on the outcomes of functional assessment
has been shown to lead to a significant increase in success (Carr et al., 1999).
Literature on the efficacy of PBS has demonstrated its effectiveness in reduc-
ing challenging behaviours in the populations studied to date. In the USA, Curtis,
Van Horne, Robertson, and Karvonen (2010) studied a school-wide PBS inter-
vention delivered to children with disabilities, developmental disorders and
emotional and behavioural difficulties. Throughout the school, positive rein-
forcement for good behaviours was applied, with person-focused interventions
implemented for children with continued challenging behaviours. Negative
referrals to the headmaster decreased from baseline by 47.8% over four years.
McClean, Grey, and McCracken (2007) implemented a PBS approach with five
adults with intellectual disabilities who presented with long-term, high severity
challenging behaviours. Rates of challenging behaviours decreased to near-zero,
with improvements sustained over two years. Moreover, the participants’ use
of psychotropic medication usage decreased by 66% over the same period.
Quality of life also increased significantly for three of the five participants; two
of whom went on to secure supported employment placements. A seven year
longitudinal study of 138 adults and children with behavioural support plans
saw challenging behaviours reduce in frequency in 77% of the population at
a follow up of 22.5 months after implementation (McClean et al., 2005). Grey
and McClean (2007) found the occurrence of target behaviours significantly
4   B. E. DAVIES ET AL.

reduced for those for whom a PBS approach was adopted, and compared this
to a control-group where no such improvements occurred.
Given the growing interest in PBS coupled with the increasing scarcity of
resources within the current service climate, there is a need to demonstrate its
effectiveness in achieving sustained behavioural change, particularly where the
model is implemented within novel populations. PBS is currently being imple-
mented within a medium secure forensic mental health service in Wales (Davies,
John-Evans, Mallows, & Griffiths, 2016). This is a novel context and, to date, the
authors have been unable to identify other similar evaluative or even descriptive
studies. The aim of this study was, therefore, to evaluate the effectiveness of PBS
in reducing the frequency, management difficulty and severity of challenging
behaviour within the forensic mental health context and to assess its longer
term impact over a period of one year. To clarify whether any changes found
were due to the PBS intervention as opposed to natural recovery, a waiting list
control group was also included within the study design. The hypotheses for
this study were that:

(1) Services users who have a PBS plan would show significant reductions
in the frequency, management difficulty and severity of challenging
behaviours.
(2) These changes would be maintained over a year to follow up.
(3) Service users without a PBS plan would show no significant changes in
their challenging behaviours over time.

Methodology
Participants
The participants in the intervention group were service users who had been
referred to the PBS team for a functional assessment and development of a
PBS plan. Initially twenty-two such participants were identified: five were
subsequently discharged six months after their PBS plan was implemented
(Intervention Full Group), leaving seventeen for whom complete data for a
year post intervention were collected (Intervention Sub Group). Participants
in the control group comprised seventeen service users on the waiting list for
referral. The demographics at baseline for the three groupings are shown in
Table 1 below.
There was a smaller proportion of men in the control group (59%) com-
pared to the intervention groups (82% and 88%). However, a similar range of
ages was represented in all three groups, with average ages between 35 and
37 years, and with the majority in their 20s and 30s. Mental health diagnoses
were comparable between the three groupings: the most prevalent diagnosis
being schizophrenia (59% in all groups), with between a quarter and a third also
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY   5

Table 1. Participant demographics.

Control group Intervention full Intervention sub
Demographic categories (n = 17) group (n = 22) group (n = 17)
Gender Males 10 (59%) 18 (82%) 15 (88%)
Females 7 (41%) 4 (18%) 2(12%)
Age 20–29 years 6 (35%) 7 (32%) 7 (41%)
30–39 years 5 (29%) 8 (36%) 6 (35%)
40–49 years 4 (24%) 4 (18%) 2 (12%)
50–59 years 1 (6%) 2 (9%) 2 (12%)
60–69 years 1 (6%) 0 0
70–79 years 1 (6%) 1 (5%) 0
Mean Age (years) 36 37 35
Diagnosis Borderline 5 (29%) 6 (27%) 6 (35%)
personality
disorder
Antisocial person- 4 (24%) 7 (32%) 5 (29%)
ality disorder
Bipolar affective 2 (12%) 2 (9%) 1 (6%)
disorder
Depressive mood 2 (12%) 2 (9%) 2 (12%)
disorder
Schizophrenia 10 (59%) 13 (59%) 10 (59%)
Schizoaffective 2 (12%) 2 (9%) 2 (12%)
disorder
Delusional 0 1 (5%) 0
disorder

rated as having borderline or antisocial personality disorders. Bipolar affective

disorder, depressive mood disorder and schizoaffective disorder were reported
for around a tenth of each group.

Instruments
The checklist of challenging behaviour
The Checklist of Challenging Behaviour (CBC; Harris, Humphreys, & Thomson,
1994) was used to assess the frequency, management difficulty and severity of
participants’ challenging behaviour at each time point. This is a standardised
outcome measure that was designed to be completed by carers. It comprises
a list of 14 aggressive behaviours and 18 other challenging behaviours. Each
behaviour is rated for ‘Frequency’, ‘Management Difficulty’ and ‘Severity’. The
‘Frequency’ scale ranges from 0 (Never shown this behaviour to my knowledge)
to 6 (Very frequently – Daily or more often in the past month). The ‘Management
difficulty’ scale ranges from 0 (No problem – I can usually manage this situation
with no difficulty) to 4 (Extreme problem- I simply cannot manage this situation
without help). The ‘Severity’ scale ranges from 0 (No injury- Does not appear
to cause pain or tissue damage to other person) to 4 (Very serious injury- Has
caused very serious tissue damage e.g. broken bones, deep lacerations/wounds,
or resulted in hospitalisation and/or certified absences from work for whatever
reasons).
6   B. E. DAVIES ET AL.

Table 2. Changes made to the original CBC for forensic setting.

Original version
Taking food or drink from others?
Eating inappropriate things (e.g. rubbish, faeces,
dangerous objects)?
Engaged in stereotyped behaviour
Smearing or flicking faeces (or anal probing)?
Refusing to do things (e.g. to eat or to move)?
 
 
Forensic setting version
Taking belongings from others?
Eating inappropriate things (e.g. batteries, dan-
gerous objects)?
Removed
Removed
Refusing to do things/ non-compliance (e.g. to
eat, to move, trading or bartering)?
Added: Expressing anti-social views or negative
attitudes (e.g. pro-paedophilia, misogynistic
views, anti-establishment)
Added: Directly influencing and controlling other
service users and staff

Each item is first rated on its frequency of occurrence by the carer. For those
behaviours rated as 0 for frequency the other ratings are not sought. Any scores
of 1 or above for frequency would warrant scoring the other scales. On comple-
tion of the CBC, the overall score for each of the scales is calculated by summing
all ratings in that scale; these total scores were used by the developers of the
measure (Harris et al., 1994) to assess inter-rater reliability, inter-respondent relia-
bility and test retest reliability. They found satisfactory levels of reliability (critical
values of rs being significant at the p < 0.05 level for all three rating scales: fre-
quency, management difficulty and severity). However, they did highlight that
there was a negative correlation between the number of behaviours recorded
and the reliability of the scales. Validity of the behaviours and the rating scales
were based on existing checklists of challenging behaviours, discussions with
clinicians and reviews of violent incidents within the hospital setting. Harris
and colleagues therefore concluded that the content validity of the CBC is high.
As the CBC was designed for use within a learning disability population, it
was deemed important to adapt it slightly for the current study to capture the
challenging behaviours typically found within forensic settings. Therefore, in
the ‘Other Behaviours’ section the authors removed and added some items and
changed the wording of some items. These changes are shown in Table 2 below.

Procedure
The ultimate intention of the service was that the vast majority of service users
would eventually have a PBS plan. Resource constraints within the service meant
that this process would have to be staggered over a considerable length of time.
Ward staff and clinical teams referred individuals for functional assessment and
PBS plans, based on their decisions around clinical need rather than for the
research. The study included these as participants in the intervention group
on a first come, first served basis. Control group participants remained on the
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY   7

waiting list. Comparability of the two groups in terms of demographics and

diagnosis was checked in order for the study to proceed.
The CBC was completed for all participants at baseline. This involved
researcher interviewing a member of ward staff who knew the service user
well (typically the person’s primary nurse) to complete the CBC. For those in
the control group a second CBC was completed with ward staff either prior
to them leaving the service a PBS intervention commencing, typically after an
average interval of 27 weeks (range 10–74 weeks). For those whose PBS plan
was implemented, the CBCs were administered on a three monthly basis for
a year, this was a part of routine clinical practice and the data were collected
by the first author and an assistant psychologist. It was not always possible for
the same staff member to complete the repeat CBCs for the same participants
because of ward moves, staff changes and availability. Each time a CBC was
completed for every participant their scores were calculated and this data were
kept by the first author, and any changes in comparison to previous scores were
fed back to the participant’s clinical team and to the participant themselves.
The information gained formed part of service users care and treatment plan
review reports. This was the same for the control and intervention groups. The
control group was in receipt of the usual treatment offered in the medium secure
forensic mental health unit and this would include medication, psychological
interventions offered exclusively by psychologists, and activities offered on a
group basis i.e. block treatment.

Intervention
The intervention was an individualised PBS Plan for each participant in the
experimental group based on a functional assessment of their behaviour. The
functional assessments were conducted by administering the Brief Behavioural
Assessment Tool (Smith & Nethell, 2014), and Contextual Assessment Inventories
(McFee, Carr, Schulte, & Dunlap, 2004), for each behaviour, with staff. A client
assessment would be completed with the service user, this was designed by
the first author and is yet unpublished. It aims to gain an understanding of key
motivators, distressors, preferred support and other quality of life factors from
the perspective of the service user. After these were completed and analysed a
behavioural formulation would be developed highlighting slow triggers (setting
events), fast triggers (discriminative stimuli) and maintaining functions. Service
users were also closely involved in the results of the functional assessments,
as understanding the triggers and reinforcers for their own behaviours was
considered a key part of the intervention.
At this stage a meeting would be held involving the service users’ psycholo-
gist, primary nurse and occupational therapist. They would select PBS interven-
tions based on the formulation of the person’s behaviour. The focus of these
primary preventative strategies was to improve service users’ quality of life. PBS
8   B. E. DAVIES ET AL.

plans were developed by the first author and the assistant psychologist. The
intervention focussed mostly on proactive strategies that included service users
undertaking activities associated with their own personal goals, skill develop-
ment, more consistent interaction between staff and service users, staff man-
aging environmental triggers wherever possible, and increasing consistency in
managing behavioural incidents that did occur. A further critical aspect of the
intervention was that the PBS plans were designed collaboratively between
service users, ward staff and clinical teams to develop a more comprehensive
and holistic understanding of the individual’s circumstances and expand the
ownership of the treatment approach amongst all key stakeholders. In addition,
the plans were written in the first person, using easy-read language to promote
service user involvement, understanding and staff empathy.

Ethical approval
The Research and Development Department of the NHS Health Board confirmed
that this study did not require ethical approval.

Statistical analysis
All data were entered into IBM SPSS version 20 for Windows and checked for
accuracy by the first author. Data were described and distribution was checked
by calculating a z score to assess skew and kurtosis. As a number of the variables
were not normally distributed, the Wilcoxon Matched-Pairs Signed-Ranks (two-
tailed) non-parametric test was used to assess within-group differences over
time, and the Mann-Whitney U-test (two-tailed) was used to assess between-
group differences.

Results
The means, medians and ranges of scores for aggression frequency, manage-
ment difficulty and severity and other challenging behaviour frequency and
management difficulty at baseline, are shown in Table 3. Although mean scores
were slightly higher in the control group, no significant differences were found
when compared to the Full or Sub Intervention groups. Also, no significant dif-
ferences in scores were found between the 22 participants in the Intervention
Full Group compared to the 17 in the Intervention Sub Group.
The scores obtained over time for the five groupings and the significance
of any changes are shown in Tables 4 and 5. Marginal decreases in scores were
noted for the control group between T1 and T2, but none of these changes
achieved statistical significance. In contrast, significant decreases were seen
in the Intervention Full Group between T1 and the three-month data point in
aggression frequency (7.55–4.64), management difficulty (5.73–3.50) severity
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY   9

Table 3. Behaviour scores at Baseline.

Significant differences
Control Intervention Intervention
group full group sub group Control Control Full vs
Behaviour domains (n = 17) (n = 22) (n = 17) vs full vs sub sub
Aggression frequency 8.71 7.55 (0–23) 8.00 (0–23) n.s. n.s. n.s.
mean (Range) (0–28)
Aggression frequency 4.5 5.5 8.0      
median
Aggression management 8.12 5.73 (0–21) 5.76 (0–21) n.s. n.s. n.s.
difficulty mean (range) (0–27)
Aggression management 4.0 2.5 3.0      
difficulty median
Aggression severity 4.47 2.36 (0–10) 2.53 (0–10) n.s. n.s. n.s.
mean (range) (0–18)
Aggression severity 2.5 1.5 1      
median
Other challenging behav- 29.47 25.45 (5–43) 25.18 (5–43) n.s n.s n.s
iour frequency mean (6–57)
(range)
Other challenging 29.5 26.5 26.0      
behaviour frequency
median
Other challenging behav- 13.88 10.14 (1–26) 10.12 (1–26) n.s n.s n.s
iour management (4–38)
difficulty mean (range)
Other challenging behav- 10.0 10.0 10.0      
iour management
difficulty median

(2.36–1.09), other challenging behaviour frequency (25.45–13.95) and manage-

ment difficulty (10.14–3.82). Aggression frequency and management difficulty
between time 1 and 3 months achieved statistical significance at p < 0.05, whilst
aggression severity, other challenging behaviour frequency and management
difficulty achieved statistical significance at p < 0.01. Further decreases in aggres-
sion frequency between 3 and 6 months post intervention reached statistical
significance at p < 0.01. For the other groups, with the exception of other behav-
iour management difficulty, further decreases occurred although these changes
did not represent any further statistically significant changes, they still repre-
sented a significant decrease compared to T1. Twelve months post-intervention
data were available for the Intervention Sub Group. Again, significant decreases
were seen between T1 and the three-month data point in aggression frequency
(8.00–4.24) management difficulty (5.76–2.76 to 6.53) and severity (2.53–1.18),
other challenging behaviour frequency (25.18–13.29) and management diffi-
culty (10.12–4.34). These changes reached p  <  0.05 statistical significance in
relation to aggression frequency and severity, the other three group achieved
statistical significance of p < 0.01. Further decreases were noted at six months
post-intervention across four ratings, excluding other challenging behaviour
frequency. The reduction in aggression frequency between 3 and 6 months was
statistically significant (p < 0.05). At the 9 months data point there were further
 10 

Table 4. Behaviour scores over time.

Mean behav- Control group (n = 17) Intervention full group (n = 22) Intervention sub-group (n − 17)
iour domain
scores T1 T2 T1 3mth 6mth T1 3mth 6mth 9mth 12 mth
 B. E. DAVIES ET AL.

Aggression 8.71 (0–28) 7.94 (0–40) 7.55 (0–23) 4.64 (0–18) 2.45 (0–12) 8.00 (0–23) 4.24 (0–13) 2.65 (0–12) 2.18 (0–12) 2.35 (0–9)
frequency
(range)
Aggression 8.12 (0–27) 7.53 (0–34) 5.73 (0–21) 3.50 (0–23) 1.64 (0–13) 5.76 (0- 21) 2.76 (0–14) 1.71 (0–13) 0.76 (0–5) 1.53 (0–8)
management
difficulty
(range)
Aggression 4.47 (0–18) 3.24 (0–17) 2.36 (0–10) 1.09 (0–7) 1.05 (0–10) 2.53 (0–10) 1.18 (0–7) 1.12 (0–10) 0.82 (0–5) 0.88 (0–5)
severity
(range)
Other 29.47 (6–57) 26.65 (5- 52) 25.45 (5–43) 13.95 (0–34) 13.77 (0–33) 25.18 (5–43) 13.29 (0–34) 13.65 (0–33) 11.18 (0–31) 14.35 (0–41)
challenging
behaviour
frequency
(range)
Other 13.88 (4–38) 11.71 (1–33) 10.14 (1–26) 3.82 (0–13) 3.95 (0–9) 10.12 (1–26) 4.35 (0–13) 3.71 (0–9) 4.59 (0–15) 6.24 (0–24)
challenging
behaviour
management
difficulty
(range)
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY   11

Table 5. Significance of within-group changes over time.

Con- Intervention full group
trol (n − 22) Intervention sub-group (n = 17)
3mth 3 mth 6 mth 9 mth T1 vs
Behaviour T1 vs T1 vs vs T1 vs T1 vs vs vs vs 12 12
domains T2 3mth 6mth 6mth 3mth 6mth 9mth mth mth
Aggression n.s. <0.05 <0.01 <0.01 <0.05 <0.05 n.s. n.s. <0.01
frequency
Aggression man- n.s. <0.05 n.s. <0.01 <0.01 n.s. n.s. n.s. <0.01
agement difficulty
Aggression severity n.s. <0.01 n.s. <0.05 <0.05 n.s. n.s. n.s. <0.01
Other challeng- n.s. <0.01 n.s. <0.01 <0.01 n.s. n.s. n.s. <0.01
ing behaviour
frequency
Other challenging n.s. <0.01 n.s. <0.01 <0.01 n.s. n.s. n.s. n.s.
behaviour man-
agement difficulty

reductions in ratings for all the groups with the exception of other challenging
behaviour management difficulty, but none of these changes reached signifi-
cance. Very slight increases across all five ratings were noted at 12 months but,
again, were not significant. Comparison between T1 and 12 months post-inter-
vention revealed statistically significant improvements on aggression frequency,
management difficulty and severity at p < 0.01 level of significance, and other
challenging behaviour frequency achieved statistical significance at p < 0.01.
When comparing other challenging behaviour management difficulty between
time 1 and 12 months the reduction was not statistically significant.
Scores for the control group at T2 were compared with those for the
Intervention Full Group at six months and the Intervention Sub Group at twelve
months. This revealed significant differences between control T2 and interven-
tion full group at 6  months at p  <  0.01 for other challenging behaviour fre-
quency and management difficulty, and at p < 0.05 for aggression frequency
and management difficulty. There was no significant difference for severity. In
considering control T2 and the subgroup at 12 months significant differences
at p < 0.01 was found for other challenging behaviour frequency and at p < 0.05
for aggression frequency, aggression management difficulty and other challeng-
ing behaviour management difficulty. Similarly no significant differences were
found between aggression severity control T2 and sub-group at 12 months.

Discussion
This research has shown that the introduction of PBS was effective in reducing
the frequency, management difficulty and severity of aggression and other chal-
lenging behaviour within this mental health forensic population. Significant
reductions were found in the intervention full group and in the intervention
sub group as soon as 3 months after the implementation of their PBS plans,
12   B. E. DAVIES ET AL.

and there was no return to baseline levels after six months and up to a year
after implementation, respectively. There were no significant differences in
scores between the intervention groups and the control group at baseline,
but this changed at post intervention, with the former showing significantly
lower scores in aggression frequency, management difficulty, severity, other
challenging behaviour frequency and management difficulty. Improvements
for the intervention group were not seen in every domain for every person,
some deterioration was evident, particularly with respect to other challenging
behaviours frequency and management difficulty in the intervention sub group.
Comparison between time one and 12 months showed no significant differences
in relation to other challenging behaviour management difficulty, which may
indicate further research into the impact of PBS on specific types of challeng-
ing behaviours may be useful further research. Such variability would however
indicate absence of bias. Conducting reliability tests at each data point would
have been desirable but it was felt that this would have made the workload less
acceptable to the ward staff.
The current findings are similar to those found in learning disability and child
populations (Curtis et al., 2010; Grey & McClean, 2007; McClean et al., 2007,
2005) who similarly found long-term reductions in the incidence of challenging
behaviour. These outcomes give support to the restraint reduction agenda and,
more broadly, to the plethora of policy guidance that has promoted PBS-based
approaches in the prevention and management of challenging behaviour in
multiple contexts (e.g. Department of Health, 2014; Mind, 2013, 2015; National
Institute for Health & Care Excellence, 2015a, 2015b; NHS Protect, 2014; National
Offenders Management Services (NOMS) (2013); Royal College of Nursing, 2013;
Skills for Care & Skills for Health, 2014.
There are some limitations to this study; this evaluation was carried out in
a clinical setting so natural inconsistencies arose. For example, different staff
respondents completed the Checklists of Challenging Behaviour if service user
had moved wards. If service users did move wards, efforts were made to collect
data from primary nurses in both ward environments to improve the accuracy of
the data. Personal factors such as the relationships staff had with services users,
their confidence in managing challenging behaviour and the environment in
which they interacted with a service user (e.g. a recovery/ rehabilitation ward or a
more restrictive intensive care unit) may also have impacted on their completion
of the checklists. However, such extraneous factors may be expected to result
in more variable data, rather than the clear, steady patterns of improvement
shown in the intervention groups and the general lack of change evident in
the control group.
Prescribing PBS as a specific, replicable intervention is fraught with difficul-
ties. PBS plans are, by their nature, very person centred. For this reason, the spe-
cific nature of the interventions would have been very different for every service
user. It would also be useful to include an assessment on the quality of the PBS
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY   13

plans within future research, to ensure that this is not a variable impacting on
the efficacy of plans. Each PBS plan, as prescribed in the literature guidance, was
based on a functional assessment of the individual’s behaviours and tailored to
their personal circumstances. Although each intervention had the core compo-
nents of primary and secondary prevention and crisis management, with the
focus on primary prevention as required by the PBS approach, service users did
not experience a consistent, manualised process, as each intervention was indi-
vidualised to their specific needs. Such individualised assessment, intervention
development and implementation is time intensive, requiring detailed data
gathering, intervention design and staff training around individuals’ specific
requirements. It also requires a good grounding in the PBS approach by the
responsible clinicians, such knowledge that cannot be assumed. However, the
significant improvements demonstrated in the intervention groups compared
to the lack of change in the control group who experienced only the usual
treatment approached within the forensic setting, would suggest that such
investment is worthwhile and potentially, ultimately cost-effective in terms of
treatment efficacy.
A further limitation with this study is associated with natural inconsistencies
that arise in undertaking service evaluations within a clinical context, such as the
inevitable changes in staff respondents, ward changes and discharges that can
jar with research needs. However, while these inconsistencies are undesirable
within a research context, they do reflect the real world and, so, emphasise the
validity of the results for regular clinical settings. In the future a randomised
control trial across a number of forensic services may be helpful in addressing
methodological issues of such a small scale opportunistic study and gaining a
fuller understanding of the efficacy of PBS in these contexts. Finally, the partic-
ipants in the intervention groups were mainly men, so further exploration of
the efficacy of PBS not just generally, but specifically within the female forensic
mental health population would be beneficial.
This is however, to the authors’ knowledge, the first publication assessing the
efficacy of the implementation of the PBS model within the context of foren-
sic mental health. As PBS is now being implemented more widely in forensic
services, and its applicability being recognised for other vulnerable groups of
people, so it is increasingly important that its efficacy is assessed in a wide range
of contexts. Further research in the area remains necessary to discover whether
these findings are generalisable to other settings. In future research it would be
helpful to look at the impact on reactive practices such as restraint, as required
medication, break-away techniques and wider restrictions. Also, quality of life
has not been directly measured within this study, as this is a primary aim of
PBS this should be included in future studies on the efficacy of PBS in forensic
settings.
In conclusion, PBS was found to be effective in reducing the frequency, man-
agement difficulty and severity of challenging behaviour in a forensic mental
14   B. E. DAVIES ET AL.

health population. It was introduced in the context of government guidance and

positive outcomes within other vulnerable populations who present behaviours
that challenge. Ideas for further research have been identified.

Acknowledgements
The authors would like to thank the staff and service users who have been involved in
the PBS project and the management team for their on-going support.

Disclosure statement
No potential conflict of interest was reported by the authors.

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