Case Study: Redirecting Behaviour Through Positive Behaviour Support at Baldock Manor Hospital
A real outcome service user case study
Service User Profile
Service User: Anonymised
Primary Diagnosis: Schizophrenia
Presenting Needs:
- Long-standing pattern of property damage through drawing and writing on walls
- Previous eviction from a care home as a result of property damage
- Behaviour continuing following admission to Baldock Manor Hospital
- Requirement for a safe and appropriate outlet for creative expression
- Property-related risks creating a significant barrier to identifying a suitable discharge placement
This case study demonstrates how the team at Baldock Manor Hospital used Positive Behaviour Support (PBS), multidisciplinary formulation and person-centred care to understand the need behind a long-standing behaviour, rather than simply attempting to prevent it.
By recognising the importance of art to the patient and finding a safe, meaningful way for him to express his creativity, the team successfully managed a behaviour that had previously resulted in the loss of a placement and had become a significant barrier to discharge.
Background
The patient was admitted to Baldock Manor Hospital with schizophrenia and a long history of behaviour that challenged in the form of property damage.
He had previously been evicted from a care home because of repeatedly drawing and writing on walls. Following admission to Baldock Manor Hospital, the behaviour continued and proved difficult to manage within the ward environment.
It also presented a longer-term challenge.
As discharge planning progressed, potential care providers expressed concerns about their ability to manage the risk of property damage. A behaviour that had already contributed to the breakdown of one placement was therefore becoming a significant obstacle to securing another.
Simply preventing the patient from accessing writing materials did not address why the behaviour was occurring. The team needed to understand what drawing and writing represented to him.
Understanding the Need Behind the Behaviour
From the patient’s perspective, what others regarded as property damage had a very different meaning.
He saw himself as an artist.
Drawing and writing were important forms of creative expression and closely connected to his sense of identity. Rather than viewing the behaviour solely as something that needed to stop, the team recognised that he had a genuine need for an appropriate outlet through which he could continue expressing himself creatively.
This shifted the focus from:
“How do we stop him drawing on the walls?”
to:
“How can we help him create art in a way that meets the same need without causing damage?”
That distinction became central to the approach that followed.
A Positive Behaviour Support Approach
The psychology and therapies team used Positive Behaviour Support and team formulation to develop a shared understanding of the behaviour and identify an alternative approach.
Importantly, this wasn’t confined to one clinical discipline.
Support workers, nursing staff, the medical team and activities coordinator were brought together with psychology and therapies, allowing those who spent time with the patient in different contexts to contribute their observations and experience.
Together, the team developed a straightforward plan:
- Regular one-to-one art sessions would take place with the activities coordinator.
- Paper and writing materials would be made available whenever the patient requested them.
- Materials would be returned to the ward office after use.
- The patient could choose pieces of his artwork to give to the psychologist.
- Selected artwork would then be displayed in one of the hospital’s meeting rooms.
The plan was discussed and agreed with the patient rather than simply implemented around him.
His response was particularly positive: he was delighted by the prospect of finally having his artwork publicly exhibited.
Once the plan was introduced, the change in behaviour was clear. The patient began creating his artwork on the paper and canvases provided rather than on the walls of his room.
Twice a week, he would select pieces to hand over to the psychologist for display, often taking the opportunity to explain the story and meaning behind individual works.
The intervention had therefore achieved more than redirecting a behaviour.
It preserved something that was important to the patient’s identity, gave his creativity recognition and provided a meaningful way for him to share his work with other people.
Crucially, he stopped drawing and writing on the walls of his room.
The risk of property damage, which had previously been difficult to manage and represented a significant obstacle to discharge, was now being successfully managed through a far less restrictive approach.
Outcomes Achieved
Following implementation of the Positive Behaviour Support plan:
- Drawing and writing on the walls of the patient’s room stopped
- Artwork was instead produced appropriately on paper and canvas
- The patient engaged positively with regular one-to-one art sessions
- He was given access to art materials when requested within an agreed framework
- Selected artwork was displayed within the hospital, giving the patient recognition for something important to his identity
- The patient regularly shared the stories and meaning behind his artwork
- The risk of property damage became well managed
- A significant barrier to discharge was addressed
- The patient subsequently secured an appropriate placement
- His needs were met through a less restrictive and more person-centred intervention
With the patient now approaching discharge from Baldock Manor Hospital, an issue that had contributed to the breakdown of his previous placement no longer presents the same barrier to his progression.
What Made the Difference?
Understanding function, not just behaviour
Rather than treating the property damage purely as a behaviour to eliminate, the team sought to understand what was driving it.
Recognising the patient’s strong identity as an artist fundamentally changed the approach. His need for creative expression remained; what needed to change was the way in which that need was met.
Positive Behaviour Support
Positive Behaviour Support provided a framework through which the team could develop an alternative that was meaningful to the patient while reducing the associated risk.
Instead of simply restricting access to writing materials, they were made available within an agreed and manageable structure.
Meaningful Involvement of the Patient
The intervention was developed with the patient, not simply for him.
Having his artwork displayed gave purpose and recognition to his creativity, while allowing him to retain an important part of his identity.
The Least Restrictive Approach
The objective wasn’t to prevent the patient from creating art. It was to enable him to do so without damaging his environment.
Providing paper, canvases, individual art sessions and exhibition space allowed his needs to be met in a way that was proportionate and considerably less restrictive.
A Whole-Team Formulation
The success of the intervention was supported by contributions from across the team.
Psychology and therapies brought together support workers, nurses, the medical team and activities staff, recognising that valuable insight doesn’t sit exclusively with one profession.
The involvement of support workers was particularly important. Those providing day-to-day care can offer perspectives and observations that are essential to understanding an individual’s behaviour and developing an approach that works in practice.
Conclusion
This patient’s experience demonstrates what can happen when behaviour that challenges is approached with curiosity rather than simply restriction.
A long-standing pattern of property damage had contributed to the loss of a previous placement, remained difficult to manage following hospital admission and was subsequently creating a barrier to discharge.
Through multidisciplinary formulation, the team identified something fundamental behind that behaviour: the patient considered himself an artist and needed an appropriate way to express that part of his identity.
The solution was relatively simple, but deeply personal to him.
By providing regular art sessions, appropriate materials and somewhere for his work to be displayed, the team created an alternative that the patient actively wanted to engage with. He stopped drawing and writing on his bedroom walls, the associated property risk became manageable and a significant obstacle to discharge was removed.
Most importantly, this was achieved without taking something meaningful away from him.
Instead, the team found a way to meet the same need safely, positively and in the least restrictive way possible.
With an appropriate onward placement now secured and discharge approaching, the outcome demonstrates the value of looking beyond the presenting behaviour to understand the person, their motivations and the needs that behaviour may be communicating.
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