Understanding Behaviour Through Choice and Control in PBS: Reducing Distress by Restoring Agency
Positive Behaviour Support depends on understanding how choice and control affect behaviour. The Positive Behaviour Support knowledge hub supports providers to connect behaviour, communication, proactive support, rights and reduction of restrictive practice.
In specialist services, understanding behaviour through PBS means asking where the person may feel rushed, overruled, ignored or unable to influence what happens next. Behaviour may increase when control is lost, choices are unclear or staff decisions replace the person’s own preferences.
This reflects PBS principles and values, because support should increase dignity, autonomy and quality of life. Strong services do not use choice as decoration. They make it real, understandable and visible in daily support.
Concept Explained Clearly
Choice and control refer to the person’s ability to influence routines, support, relationships, environment and daily decisions. This may include what to wear, when to receive support, who provides personal care, where to sit, whether to join an activity, how to communicate refusal and how to recover after distress.
Behaviour may communicate that the person does not feel heard or in control. Refusal, shouting, withdrawal, repeated questioning, leaving an area or damaging property may all occur when support feels imposed. Understanding this does not mean every request can always be met. It means staff must identify where control can be safely increased and where limits need to be explained respectfully.
Why It Matters in Real Services
When choice and control are weak, services can become task-led. Staff may complete routines efficiently while the person experiences pressure, loss of dignity or lack of say. This can create repeated distress around care, meals, medication, community access or shared spaces.
There are also governance risks. Restrictions may become normalised because staff believe they are preventing incidents. Commissioners and CQC will expect providers to show that support is person-centred, least restrictive and based on the person’s communication, rights and preferences.
What Good Looks Like
Strong services demonstrate that choice is built into everyday practice. Staff know how the person makes choices, how they refuse, how they show uncertainty and how much information they need. Plans identify which decisions are flexible, which are safety-critical and how staff should support control without creating confusion.
Good PBS practice gives people agency before distress escalates. Staff offer limited but meaningful options, respect refusal where safe, prepare people for unavoidable limits and avoid unnecessary power struggles. Providers should be able to evidence how increased control reduces escalation and improves quality of life.
Operational Example 1: Control During Personal Care
Step 1 – Context identified: A person in supported living became distressed during morning personal care, especially when staff selected clothing and began prompting quickly. They pushed clothes away and sometimes shouted.
Step 2 – Control issue explored: The provider reviewed the routine and identified that staff were making decisions to save time. The person had limited opportunity to choose clothing, timing or the order of support.
Step 3 – Support changed: Staff offered two clothing options, allowed the person to choose whether washing happened before or after breakfast, and used a visual sequence so the person could see what was coming next.
Step 4 – Practice made consistent: The care plan was updated with clear choice points. Staff were briefed that choice had to be offered before support began, not after distress appeared.
Step 5 – Effectiveness evidenced: Distress reduced, personal care was completed more calmly and records showed fewer incidents linked to clothing and timing. The provider evidenced that restoring control improved dignity and cooperation.
Deepening the Understanding: Choice Must Be Real and Understandable
Choice is not meaningful if the person cannot understand it, if too many options are offered, or if staff ignore the answer. Strong PBS services check whether choice is accessible. Some people need visual options, objects of reference, extra processing time or repeated practice when calm.
Control also includes the right to refuse where it is safe to do so. If every refusal is treated as a behaviour problem, the person may learn that escalation is the only way to be taken seriously. Providers should be able to evidence how they balance safety, rights and autonomy in practical support.
The related article on seeing behaviour as communication in PBS reinforces why refusal, resistance and distress should be understood as messages about support, not simply barriers to task completion.
Operational Example 2: Choice Around Mealtimes
Step 1 – Pattern recognised: In a residential service, a person often left the dining room when meals were served and returned later asking for snacks. Staff initially recorded this as poor mealtime engagement.
Step 2 – Choice barriers reviewed: The team found that meals were plated before the person arrived, seating was fixed and staff encouraged eating at the same pace as others. The person had little control over food presentation or timing.
Step 3 – Support adapted: Staff introduced a visual menu choice earlier in the day, offered two seating options and allowed the person to decide whether food was plated or served in separate bowls.
Step 4 – Risk managed: Nutritional monitoring continued, but staff stopped pressuring the person to eat immediately. If the person left, staff offered a planned return option rather than unstructured snacking.
Step 5 – Outcome evidenced: The person stayed for more meals, ate a wider range of food and showed fewer signs of distress. Records showed that increased control improved both nutrition and participation.
Systems, Workforce and Consistency
Choice and control must be applied consistently. If one staff member offers meaningful options and another makes decisions for the person, behaviour may increase because support feels unpredictable. Strong services use handovers, supervision and observation to check whether choice is actually happening.
Managers should review whether staff are offering choices at the right time, using accessible formats and respecting responses. Supervision should explore where staff feel pressured by time, risk or routines, because these pressures often reduce the person’s control unless actively managed.
Operational Example 3: Control During Community Access
Step 1 – Situation clarified: A person receiving outreach support frequently refused community trips after staff had already planned the destination. They became distressed when told where they were going.
Step 2 – Meaning considered: The provider identified that the person was being informed rather than involved. The behaviour appeared linked to loss of agency, not lack of interest in going out.
Step 3 – Support redesigned: Staff created a weekly choice board with three realistic community options. The person chose the destination, preferred travel method and whether the visit would be short or longer.
Step 4 – Boundaries explained: Where some options were unavailable due to weather, cost or staffing, staff used a clear “not today” symbol and offered a planned alternative rather than a long verbal explanation.
Step 5 – Evidence reviewed: Refusals reduced, community access increased and the person showed more confidence preparing for outings. The provider evidenced that shared planning improved participation and reduced escalation.
Governance and Evidence
Governance should show how choice and control are protected, reviewed and improved. Providers should be able to evidence care plan updates, PBS reviews, restriction audits, incident analysis, staff observations, supervision notes and outcome monitoring.
Strong governance looks at whether people have more say in daily life, not only whether incidents reduce. Evidence should show how choice affects participation, dignity, relationships, recovery and restriction reduction. This creates a clear line of sight from behaviour to control need, from control need to support action, and from support action to outcome.
Commissioner and CQC Expectations
Commissioners expect providers to support choice and control because this affects rights, stability and quality of life. They need assurance that services can manage risk without unnecessarily narrowing the person’s life.
CQC will expect care to be person-centred, respectful and least restrictive. Inspectors may review whether people are involved in decisions, whether staff understand refusal, whether restrictions are justified and whether leaders monitor practice. Strong services demonstrate that choice is embedded in everyday PBS delivery.
Common Pitfalls
- Offering choices after decisions have already been made.
- Using too many options when the person needs simple, accessible choices.
- Treating refusal as non-compliance rather than communication.
- Removing control in the name of efficiency or routine.
- Failing to explain unavoidable limits in a way the person understands.
- Measuring success by task completion without checking dignity or agency.
Conclusion
Understanding behaviour through choice and control helps PBS teams see distress as information about agency, dignity and support quality. Behaviour may show that the person needs more say, clearer options or better preparation before support can feel safe.
Strong providers make control practical in daily routines. When people have meaningful choices, staff respond more consistently and governance can evidence better outcomes. This strengthens PBS as a rights-based approach that improves real lives, not just incident records.