Five PBS and ABA blind spots: once you see it, you can't unsee it
Today we’re joined by Kay Louise Aldred, NdC’s Development Lead,for the sixth blog of our latest campaign ‘Against PBS & ABA’.
Kay outlines five fundamental issues with PBS and ABA behaviourist approaches, describing how perhaps the biggest blindspot of them all is that there are truly different, better ways of working.
Despite their widespread use in educational, mental health, social care and therapeutic settings, Positive Behaviour Support (PBS) and Applied Behaviour Analysis (ABA) contain critical blind spots. Once recognised, these issues fundamentally shift how we view these approaches – especially in the context of supporting Neurodivergent and Autistic individuals.
1. Not consent-based
The blind spot:
Interventions are frequently implemented on individuals rather than with them. Genuine, informed and ongoing consent is often absent, particularly for individuals who are non-speaking, considered to lack capacity or in crisis.
Why it matters:
Without true consent, support becomes coercion. People may ‘co-produce’ a plan without ever being fully informed of its purpose. Someone may be asked what they like or dislike without being told how that information will be used. This isn’t informed consent; it is data collection.
Within hospital inpatient care, many plans are developed within 72 hours of admission, driven by audit targets or internal policy. However, this rush to paperwork leaves no time for building relational safety, trust or understanding.
And when someone is newly admitted, distressed, overwhelmed or in crisis, how meaningful can their input truly be at that moment? We wouldn’t ask someone to consent to surgery during a medical emergency without first stabilising them, yet we routinely ask people to agree to long-term behavioural interventions at the same time they’re dysregulated and emotionally overwhelmed.
We often hear, “we’ve co-produced the PBS plan with the patient.” But have they been told what they’re contributing to? Have they been informed about the purpose, scope and potential impact of the plan?
More often, people are asked what they like or dislike, but without being given the full context of how that information will be used. This isn’t true coproduction, it's data collection disguised as collaboration. And without a clear, informed context, consent is limited at best and coercive at worst.
2. Built-in power imbalances
The blind spot:
PBS and ABA are built on an expert–subject model, where professionals decide what behaviour is ‘appropriate’ and how to intervene. This creates a dynamic where power rests with the staff member, not the individual.
Why it matters:
This power imbalance creates a compliance-over-autonomy culture. We measure success by how well someone fits our behavioural expectations, without questioning whether those expectations are valid, respectful or humane.
We often hear: “PBS plans help staff know the person quickly.” But how much can you truly know someone from a piece of paper? Especially one built to fit a format and pass an audit?
Audit culture reinforces this imbalance. Services are measured by how many patients who have PBS plans. And as the saying goes: “What gets measured gets actioned.” What if we flipped what gets measured to something more person-centred? What if we audited for relationship quality or experiences of felt safety, not compliance or document completion?
3. Occupies the body
The blind spot:
PBS and ABA often target bodily autonomy. Movements like stimming, rocking or repetitive speech, all natural ways of self-regulating, are redirected or extinguished. This is not because they cause harm, but because they make others uncomfortable.
Why it matters:
This teaches people to disconnect from their own bodies: to mask, to suppress. To adapt to others' expectations of “normal.” The body becomes a site of control and correction, rather than a means of self-expression, regulation and joy.
PBS plans often dictate how someone should behave rather than supporting them in understanding and expressing who they are.
It raises a hard question: who are the plans really for? Are they supporting the person or are they making staff feel more in control? Is the plan created to support the individual or to standardise processes for the service?
4. Focus on external, observable behaviour only
The blind spot:
Rooted in behaviourism, PBS and ABA focus on what can be seen and measured. Internal experiences, trauma, anxiety, unmet sensory or felt-sense safety, emotional and belonging needs, are often ignored because they’re not visible or quantifiable.
Why it matters:
A person who stops expressing distress hasn’t necessarily stopped feeling distressed: they may have learned that expressing it leads to punishment, restraint or being ignored.
And because so many plans are based on observable ‘triggers’ or behavioural patterns, they often rely on copy-and-paste approaches. What helped one person is assumed to work for all. But this totally loses the point.
Even the idea of giving someone a menu of choices for their PBS plan is limited. You can’t know your options if you’ve never experienced Neurodivergent-affirming care. "I thought Domino’s was my favourite pizza, until I tried the local independent place." Preferences are shaped by what we've been exposed to. People may not know what supports them, not because they lack insight, but because they’ve never been supported in a way that truly sees them.
5. Not relational – and the absence of love
The blind spot:
PBS and ABA often reduce human interaction to transactions: behaviours are reinforced, discouraged or redirected. The approach is procedural, not personal. Relational depth is missing. Empathy is optional. Love is nowhere.
Why it matters:
Humans are wired for connection. People thrive when surrounded by relationships built on trust, mutual respect, and emotional safety. Support without relationship is not support, it’s control.
And yet, PBS plans are often displayed on walls, in offices, in places where personal, sensitive information becomes general consumption. That doesn’tfeel relational. That feels exposed and exposing.
It raises another question: What if PBS plans were written for staff?
If a staff member slams a door, snaps at someone or has an off day, should that be recorded and followed by a consequence? For patients, this is standard. But staff are given grace, context and relational benefit of the doubt. There are systems and processes in place to defend and protect the rights of the staff, should they have difficulties in the workplace. But what about the patients? Who defends and protects their right to be dysregulated, distressed or have an off day? This is where we come in and is why we are questioning the continued normalisation of oppressive behavioural practices, masquerading as care and support.
What if everyone got that?
Final thought: the blind spot behind the blind spots
Many services operate as though there is no other way: "We have to have a PBS plan for everyone, it's in policy, CQC expect it." These services state PBS and ABA are “the best we've got.”
But what if the biggest blind spot is a lack of awareness that another way exists?
What if, instead of behavioural plans, we built relational ecosystems, where needs were met before behaviours needed managing? Where people weren’treduced to risks, triggers and responses, but seen as humans worthy of time, care, and dignity?
Once you see it...
These blind spots challenge the foundations of what is often labelled as ‘support.’ When interventions are not consent-based, reinforce power imbalances, treat the body as a site of control, ignore internal experience and lack relational depth, they may produce compliance, but not wellbeing.
…You can’t unsee it.
So what are the alternatives?
We’ve created a free interactive toolkit that supports a neurodiversity-affirming approach to care planning for Autistic individuals across health, education and social care.
The foundation of this toolkit is the Autistic SPACE Framework – a person-centred care approach developed by Dr Mary Doherty, Dr Sue McCowan and Dr Sebastian CK Shaw (2023) – which we build on by integrating a stronger emphasis on emotional safety, sensory support, relational trust, embodied understanding and human rights.
We believe that compassionate, relational and context-aware approaches are a more ethical and effective alternative to behaviourist models that prioritise compliance over wellbeing.
