Title: Opportunities and Considerations Applied Behavior Analysis in the Now-Person-Centered Landscape of Adult Services: Striving Towards Independence and Meaning

Authors: Stuart Law, Mark Malady and Brendan Böhr

Date Published/Presented: (in press)

Publication/Presentation Format: Book chapter published in Applications of Behavior Analysis to Healthcare and Beyond

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Synopsis: 

Transitioning into adulthood is a complex and often messy experience. There are a lot of selective pressures that act on the individual and success requires adaptation. When considering treatment goals for Individuals with Intellectual and Developmental Disabilities (IDDs), there is a tendency toward alleviating discomfort for people served, which can lead to limiting their experiences. This tendency interferes with full community integration through restrictive clinical practices. Learners can also experience challenges integrating into an environment if the organization has problems of leadership, inadequate staff training and management, and inefficient organizational systems. This chapter reviews the history of people with disabilities in residential settings and the ways that behavior analysts can affect change to promote effective treatment as well as respect and dignity for people with IDDs and those who support them. 

The establishment of the US Community Mental Health Centers Act of 1963 initiated deinstitutionalization; however, the Act brought new challenges for lawmakers and service providers. They were charged with developing community-based residential supports that provided quality care but also protected the rights of people with disabilities. These challenges are still being tackled today. Deinstitutionalization highlighted the varying needs of people with IDDs, which led to wavering systems of support and funding sources. Although best practices recommendations may vary across the various models, there is no data that points to an ideal one. The goals of the continuum of support logic are to match behavioral assessment to skill-building, to create growth opportunities, and to respect the values of the person served. However, many questions have not been answered related to how best to approach this situation. Behavior analysis can help answer questions in this area. 

There are two main career paths that may interest a behavior analyst relating to residential treatment settings: clinical practice, or systems management and workforce development. Though there are other career paths, the current chapter focuses on these two predominant paths. Best practices for these two career paths include a multitude of domains which are described in more detail in the full chapter. Given that supports for adult learners with disabilities have historically not been regulated, there is less published research and review of evidence-based practices in comparison to other settings (e.g., education settings, psychotherapeutic settings, Autism Spectrum Disorder). This is a fertile area of research for those interested. 

For the behavior analyst interested in the first path, clinical practice, there are various areas of skill and knowledge that are important. They include functional assessment and working with decelerative targets, skills-oriented assessment and habilitation, and teaching strategies. There are important considerations and best practices outlined in the chapter for each of these categories.

For the behavior analyst interest in the second path, behavior analytic leadership, it is important to recognize that other skills, in addition to clinical skills, are necessary since the bulk of this work is done through others. This situation makes the Organizational Behavior Management (OBM) knowledge base increasingly important for behavior analysts in leadership positions. The authors identify several key OBM strategies that behavior analysts working in service delivery should be familiar with, including systems design, feedback systems, staff training, and supervision.

Opportunity is abundant for the behavior analyst that would like to work with IDD populations. Reading the references cited in this chapter is a good starting place. It is also recommended that behavior analysts seek mentorship in their specific area of interest. Adults with disabilities have been suppressed and underserved in our society for a long time. Behavior analysts are in a unique position to help others live more meaningful lives. 

Relevance to our mission and vision: As an organization, we are committed to providing person-centered assessment and services that empower our learners to reach their self-identified goals and gain the skills to become increasingly autonomous, while respecting our learner’s rights and dignity. We also believe in creating evidence-based learning systems that use our resources effectively and efficiently for our learners and our staff. This chapter outlines best practices for behavior analysts that we strive to implement in our organization from top to bottom.  

Relevant iASK Skills Domains: Pivotal Skills, Movement, Complex Verbal Behavior, Committed Action, Community Contact, Close Relationships, 21^st Century Skills (The authors recommend several of these areas as best practices for assessment for behavior analysts considering the clinical practice path. See full article for details)

Title: Murray Sidman: Fostering progress through foundational choices

Authors: Stuart Law and Steven C. Hayes

Date Published/Presented: November 6, 2020

Publication/Presentation Format: Peer-reviewed article in the Journal of Experimental Analysis of Behavior

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Synopsis: 

Sidman is considered an innovator and a philosopher of science in the behavioral tradition. His work has widely influenced the science of behavior. Sidman’s writings demonstrate his commitment to naturalistic thought. He advocated for a psychological science that focuses on observable behavior in context without referencing mentalistic or mystic entities. While Sidman was interested in effecting broad cultural change, he also sometimes advocated for strategies that pigeon-holed behavior analysis; for example, his commitment to time-series experimental designs and inductive research. He believed behavior analysis was highly relevant to human functioning, yet rejected the use of aversive methods. Sidman had great clarity about the foundational assumptions of his work, which afforded him the freedom to speak without reservation on many matters. This article highlights a few key contributions of Sidman’s work that led the science of behavior down a progressive path: stimulus equivalence, his use of rapidly inductive and idiographic practices, and his impact on ethical practices. 

Sidman’s discovery of stimulus equivalence led the way in seeking a naturalistic approach to human language and cognition. It provided a way for thinking about symbolic language and its interaction with direct-acting contingencies. Sidman did a good job of defining stimulus equivalence in ways that avoided confusion and promoted experimentation in both basic and applied research. His precise definition also provided an analysis that did not require neurobiological connections or cognitive mediators opening the door for behavior analysts. Though the work on defining and understanding relations continues today, it would not be possible without him. 

Sidman saw the need not only to examine equivalence relations in applied and basic areas but also to explain equivalence itself. He integrated set theory into his explanation and concluded that equivalence relations were an important property of reinforcement processes that could only occur given the right set of contextual conditions. Today, relational frame theory (RFT) is the dominant research area that attempts to explain equivalence. The RFT position is that equivalence is one of many relational operants. Sidman seemed to disagree with the notion that ‘equivalencing’ is a learned process and preferred his mathematical description. Nevertheless, Sidman’s diplomacy has allowed RFT research to progress, though he warned that it is important that theories are based on parsimony, coherence, consistency and productivity and should be subjected to rigorous experimentation. While science should be cautious in its analysis and recognize there is always room for error; it is also important to take bold leaps to advance the science. Regardless of how the battle over equivalence and derived relations shakes out in the future, Sidman made an important mark on the field. 

Skinner was an advocate of idiographic designs, but Sidman canonized them. Idiographic designs are necessary for the Experimental Analysis of Behavior (EAB). It is impossible to discern the processes of change that impact the individual from a group-level analysis. It can only be accomplished with research designs that use within-subject replication. The functional principles of EAB have both precision and scope of application, which makes them extremely useful. Sidman was one of the greatest defenders of the methodological tactics of this approach as evidenced by his book Tactics (of Scientific Research). 

Applied behavior analysis has always been committed to this methodological approach; however, this approach is not true of clinical psychology. Mainstream clinical psychology has relied on randomized control trials and analysis at the level of the collective partly due to funding policies and partly a belief that analysis of individuals lacks generalizability. Nonetheless, the tides seem to be turning and now funding priorities are pointed toward process-based interventions and reinvigorating idiographic research. Mainstream psychology is starting to shed its reliance on statistical models concerned with inter-individual variation and moving toward models that focus on intra-individual variation, which echoes many of Sidman’s data-based decision-making practices. Of course, many of the idiographic statistical models proposed in clinical psychology do not mirror exactly the time series designs used in behavior analysis, but the root assumptions are the same. This consensus bridges the gap that has existed between the two fields and it might be that behavior analysts need to learn to speak a common language to expand into other domains. 

Sidman was one of the first in the field to speak out against coercive methods and believed they posed a great threat to the field. Now, most behavior analysts agree reinforcement is the first and foremost tool for therapeutic change, though it could have been different if Sidman did not speak up when he did. Nonetheless, the issue of ethics was not resolved in Sidman’s time. It is an issue that requires regular consideration. It’s important to consider the impact of expanding our knowledge base on scientific methods, providers, and the support of the culture overall. For example, it is important we examine how we select and shape behavior so we don’t run the risk of earning the mistrust of other professionals, the public and learners. We also need to continue to explore the best ways to promote choices linked to a person’s long-term interests. There are implications for stimulus equivalence and derived relational responding research since it has become evident that the traditional approach to functional analysis (i.e., four functions) is less useful with verbally sophisticated learners. Behavior analysts need to learn how to evaluate learner’s values, goals and committed actions beyond the four functions, and learn to shape relational repertoires that lead to self-advocacy and self-direction. It is critically important that research in this vein continues to be refined with diligence and address concerns such as dignity-of-risk in a naturalistic way. The science should inform best practices that foster health, safety and dignity. 

Murray Sidman was known for his quiet and humble manner – but beneath that exterior

he was a warrior for behavioral science. His clarity of vision and depth of commitment to a

natural science of behavior made a lasting impact. In each of the three areas we have reviewed he

took strong stands, but he was never rigid; he made adventurous leaps, but he was never

scientifically irresponsible or impulsive; he spoke forthrightly, but he was always prepared to

listen. His actions have had a striking impact on our field – one that continues to expand, not just

in what we know now, but also how we know it.

Relevance to our mission and vision: Many of Sidman’s philosophical ideas resonate with the mission and vision of High Sierra Industries. We are a person-centered organization, which inherently assumes that we care about fostering growth while also protecting the safety and dignity of those we serve. We also adhere to the notion that effective change can only be made with an analysis at the level of the individual and our flexible, individualized assessment process exemplifies our commitment to this notion. Moreover, we are an organization that respects the rights and dignity of every individual, and we think carefully about how to affect change through non-coercive means. It is evidenced by our inclusion of an entire domain in our assessment tool that is dedicated to exploring participants’ values, goals, and committed actions. 

Relevant iASK Skills Domains: Complex Verbal Behavior, Committed Action

Title: Fluency and the Maintenance of Skills Related to Sex Laws for Individuals Adjudicated for Illegal Sexual Behavior.

Authors: 

Date Published/Presented: 2020

Publication/Presentation Format: Peer-reviewed article in Behavior Analysis in Practice. B.

Full Article

Synopsis: Sally A. Hamrick, Sarah M. Richling, William T. Davis, John T. Rapp, Emily . Longino, Peta Kimber, Kristen M Brogan and Stuart Law

The current study used a fluency-based treatment package to help two individuals adjudicated for illegal sexual behavior learn Alabama sex laws as part of their residential treatment. The study was specifically interested in evaluating whether using 100 percent accuracy criteria coupled with rate-based criteria of mastery leads to skill retention over a long period of time. Many studies have evaluated fluency outcomes but few that provide specific criteria for terminating intervention. Research also suggests that the common mastery criterion used by Board Certified Behavior Analysts (BCBAs) is 80 percent accuracy across three consecutive days, which is derived from common clinical practice in their previous supervised roles rather than experimental evidence. There is a clear gap both in traditional ABA literature and in the fluency-based literature with regard to the type of mastery criteria that yields the desirable fluency outcomes: retention, endurance, and application. This study was mainly interested in learners retaining their skills since they had to take an exam on Alabama sex law both at the beginning and end of their habilitation. 

The study used a variety of procedures to teach the laws to their predetermined mastery criteria. These included using flashcards to practice the definitions of the laws. In fluency-based instruction, there is a procedure that emphasizes important features of using flashcards summarized as SAFMEDS. This stands for say-all-fast-one minute-every-day-shuffled. This experiment used a SAFMEDS-like procedure combined with other techniques to promote successful learning. In the first phase, the learners were given the opportunity to study the front and back of the flashcards (exposure) before practicing saying the definitions only when presented with the titles of the law (i.e., the front of the flashcard) during a 5-minute time interval. In this first teaching phase, the learner also had a word bank with the titles of the laws available to choose from. During the 5-minute practice timing, the experimenter would also discard the flashcard in one of two piles depending on whether the learner answered correctly or incorrectly, which served as visual feedback for the learner. If the learner answered incorrectly, the experimenter would also require the learner to provide the correct answer once while looking at the answer on the flashcard before moving on to the next flashcard. Per SAFMEDS guidelines, the flashcards were shuffled before restarting. The second phase promoted independence in responses by removing the initial exposure before timings and the word bank. That way learners had the opportunity to practice the flashcards under conditions more similar to those of a test. When the learners met the mastery criteria, intervention ended and experimenters periodically conducted maintenance probes to see if the learner’s performance retained without practice. 

The mastery criteria to qualify for ending intervention was 100 percent accuracy plus a predetermined rate per minute across three consecutive days. The predetermined rate per minute (aka, responses per minute) per each set was 11rpm, 12 rpm, and 13 rpm for sets 1, 2, and 3 respectively. Follow-up probes were conducted weekly for 10 weeks to see if the learners’ performance maintained. During follow-up probes, the word bank and discriminated discard piles were not available. They were also not given time to study the flashcards before the timing and no consequences or feedback was given with regard to correct and incorrect responses. Therefore, the two different discard piles were also eliminated. The experimenters measured the accuracy and rate of response for all sessions. 

Results showed that both participants were able to reach the mastery criteria: 100 percent accuracy within the specified rate of responding across three consecutive sessions for all three sets. One participant required a slight modification whereby the experimenter shortened the timing length to 1 minute, then probed performance at 5 minutes once the mastery criteria had been reached. After this modification, the learner was able to meet the criteria at 5 minutes. The weekly follow-up probes demonstrated a high level of accuracy retention. With few exceptions, the two participants maintained 80% or greater accuracy during follow-up probes for all three sets. The learner’s rate of responding did drop more substantially than their accuracy during follow-up probes, but in many instances, the rate was within or close to the aim. 

This study provides further evidence that using fluency-based procedures leads to retention of skills, at least in terms of accuracy. This study evaluated an accuracy criterion of 100 percent for three consecutive days, which differs from the typical 80 percent accuracy criterion typically used by practitioners. In this study, participants maintained accuracy at or above 80 percent accuracy in follow-up, which is a decrease in accuracy from training. Note that studies that have used 80 percent accuracy as the mastery criterion usually see dips in accuracy at follow-up below 80 percent. The authors recommend that practitioners consider adopting an accuracy criterion of 100 percent for three consecutive days for training to promote maintenance at or above 80 percent at follow-up. (There are limitations mentioned in this study. Please see the full article for more information.) 

Relevance to our mission and vision: Our mission is to develop, deliver, and use learning systems that benefit people with disabilities and those who support them. This study is an example of an exploration into the most efficient and effective components of learning systems. We must understand how each component of a learning system impacts a learner’s progress and maintenance of skills so that our learners can get the most benefit out of the programs we offer. 

Relevant iASK Skills Domains: Pivotal Skills (all maybe)

Title: The centrality of sense of self in psychological flexibility processes: What the neurobiological and psychological correlates of psychedelics suggest

Authors: Steven C. Hayes, Stu Law, Mark Malady, Zhuohong Zhu, and Xiaoyu Bai

Date Published/Presented: November 2019

Publication/Presentation Format: Peer-Reviewed Journal Article

Original Article 

Synopsis: 

Psychedelics (hallucinogens or drugs that alter a person’s awareness of their surrounding as well as their own thoughts and feelings) have been a part of cultural and therapeutic practices for a long time. However, certain cultural pressures have impeded good research in their therapeutic advantages. There has been renewed interest in psychedelics’ role in psychological processes. By and large, the scientific community recognizes that psychedelics cannot be a stand-alone treatment and any benefits to be gained from their use will have to be coupled with evidence-based therapies. Research needs to focus on an empirical verbal/cognitive model and how it affects the psychedelic experience. Acceptance and Commitment Therapy (ACT) seems to be a prominent framework for structuring the use of psychedelics. This paper will explore the implications of this and how it relates to psychological flexibility processes. Since psychedelic experiences involve verbal/cognitive processes, there is utility in examining it in terms of the basic verbal unit of analysis of ACT and Contextual Behavior Science (CBS), relational framing. There are two benefits to this approach. First, it ties psychedelic experiences to a scientific and naturalistic process at the psychological level thereby demystifying it. Second, constructing a basic relational framing account of psychedelics (that also coheres with neurological data) could help providers and researchers use the ACT model more effectively. Since much of the research in psychedelics agree that psychedelic experiences involve changes in the sense of self and perspective-taking, this article explores sense of self from a Relational Frame Theory (RFT) approach and argues that it is a naturalistic way to understand psychological events in psychedelic experiences.

The dawn of RFT research expanded the analysis of verbal behavior/cognitive events, allowing for an analysis of more comprehensive subjects including sense of self. RFT has established relational framing as a behavioral operant. Relational operants are central features of verbal/cognitive events and provide a way of conceptualizing the sense of self in a naturalistic way. The verbal sense of self emerges over time and can be taught with various methods. Perspective taking and theory of mind skills (TOM) are central features of sense of self. From an RFT standpoint, perspective-taking, and theory of mind skills are relational framing skills. Perspective-taking skills in RFT emerge from deictic frames. Deictic frames establish the perspective of the speaker. The most common deictic frames are I-you, here-there, now-then. These can be trained starting with simple non-arbitrary conditional discriminations and progress to increasingly more complex and arbitrary discriminations. These have been correlated with perspective taking and TOM skills. From basic research on deictic frames a conceptualization of sense of self has emerged in ACT and RFT. 

There are three main categories of sense of self according to early ACT and RFT literature that serve as a naturalistic foundation. The perspective-taking self is the verbal I/here/now. Essentially, it is the vantage point of observation (aka, deictic ‘I’) of a person. From this point of view, it seems that anything “I see/do” are a part of “me.” Other words used for this self are the “observing self” or the “transcendent self.” The experiential self (self-as-process) is an ongoing process of verbal self-awareness. This is when the person is interacting with a combination of private events and external events and notices things such as “I feel sleepy.” Another word for it is “knowing self.” The conceptualized self (self-as-content) is our self-story, which includes preferences or qualities that we use to define ourselves (i.e., being smart, kind, mean, etc.) All three co-evolved and are interrelated, but the perspective-taking self is central to understanding psychological flexibility processes. Perspective-taking relational frames can combine with other relational frames which allow people to take the perspective of others in more comprehensive ways. 

Research has shown that the RFT measures of sense of self correlate with psychological health. Of particular interest to psychedelic research are the findings that have emerged that suggest that it is better to frame perspective-taking in a hierarchical fashion rather than in a coordinative fashion. That is, it is more useful to take the perspective of self as containing (hierarchical) all your experience than being separate or apart from them (distinction) which seems to be an important difference for exploring the features of self-experience under the effects of psychedelics. 

There are some psychological correlations with psychedelic experiences that can serve as a naturalistic unit of analysis, mainly related to complex verbal behavior. Psychedelic experiences seem to be highly influenced by complex verbal repertoires. However, there are many limitations of the research on psychedelics as well as in relational framing that have made it difficult to measure the psychological effects of psychedelics. Despite these limitations, some broad categories of effects have been reasonably captured by measurement tools such as direct observations, verbal reports, and questionnaires, but historically these have been described in non-naturalistic terms (i.e., the ego, transcendence, alternate dimensions of reality, soul). To move the analysis forward, it is important to have a scientific account of the psychological sense of self, which then can be used to explore how the psychological account of psychedelic experiences align with the neurological effects. 

One of the biggest effects of psychedelic experiences tends to be movement from a judgmental sense of self to a perspective-taking sense of self. The effect is known by several names such as “ego dissolution,” “positively experienced depersonalization,” “decentering,” and “oceanic boundlessness.” These effects can be felt as an increased sense of unity and reduced self-importance for example. Others report that they experienced a blurring of boundaries between themselves and everything else in the environment and have a profound connection to everything (oceanic boundlessness). This sense of oceanic boundlessness has also been reported in mindfulness practices. Studies have shown that these types of experiences do correlate with good treatment outcomes and there is also some neurobiological data that suggest good outcomes as well. It is, however, important to do more empirical and controlled research using precise measurements to better understand the utility of these effects. 

Psychedelics also seem to change stimulus control and motivational functions. For example, people may report that they “saw” sounds or had vivid visual experiences in the dark or with their eyes closed. From an RFT perspective, this seems to be explained by changes in motivational variables, rule-governed behavior, or stimulus functions related to present-moment awareness, but there is not enough research to parse out the important distinctions that apply in these situations. There are, however, some important known neurobiological effects. For example, broadly speaking, psychedelics seem to reduce the activity in the areas of the brain that are related to our conceptualize self (the self that tends to be evaluative) and increase the activity related to the perspective-taking self. Note that mindfulness practices can have similar effects, although to a lesser extent. As a sidenote, psychedelics have also been shown to increase neuroplasticity. 

  Another potential effect of psychedelic use is feeling a sense of insightfulness. Some people report feeling like they had a profound experience and gained important knowledge while under the influence of psychedelics. Interestingly, these rules derived from the psychedelic experience can persist long after and can even lead to changes in values. This is not typical with the use of other substances where someone may say something that sounds profound in the moment under the influence (for example of alcohol) but sounds silly or irrelevant once they are sober. For this reason, this seems to be an important outcome of psychedelic experiences and warrants a more naturalistic psychological account to fully understand it. 

Psychedelic experiences can also cause intense undesirably experiences such as feelings of fear or losing control and though they can be heavily influenced by environmental supports, psychedelics can lead to experiencing anxiety. These experiences can often be resolved through acceptance work in a controlled environment. Psychedelics could provide research opportunities related to exploring negative events and working on acceptance processes. Psychedelic experiences can serve as a platform for transforming experiential avoidance into experiential acceptance.

More than 30 years ago, Hayes (1984) linked spiritual transcendence to learned perspective-taking verbal skills. Developing a perspective-taking sense of self requires the person to “see themselves seeing” or develop a sense of observing their experience without necessarily being a part of it. This is odd and difficult behavior, though reaching the point where your sense of self is that of an observer makes it easier to “see” rules without necessarily following them. Said another way, the perspective-taking self helps increase psychological flexibility processes such as defusion and acceptance and increases your sensitivity to direct contingencies as well. These psychological flexibility processes parallel many of the neurobiological and psychological effects of psychedelics. At the neurobiological level, psychedelics tend to decrease the tendency to self-evaluate or create self-narratives (which can make you insensitive to your current environment) and enhance the perspective-taking self. This is evidenced by the fact that people who experience neurobiological changes related to the sense of self AND also report a reduction in the conceptualized sense of self have better clinical outcomes. Psychedelic research supports the psychological flexibility model and its emphasis on expanding the perspective-taking self or the hierarchical deictic “I.” 

The perspective-taking self is central to psychological flexibility. This centrality has never been reflected in the psychological flexibility hexagon used to demonstrate how the processes of flexibility are related. A new rendition of a model that takes the centrality of the perspective-taking self into account has emerged where the perspective-taking self has been hierarchically framed (see the article for full description). Essentially, this model reflects the arguments provided herein that awareness is the foundation of psychological flexibility from which the other processes emerge.

There is still a lot of research to be done on the concepts proposed here. That said, preliminary findings suggest that psychedelic research can contribute to the development and refinement of psychological flexibility processes and the sense of self. Conversely, Contextual Behavior Science (CBS) research can help establish appropriate therapeutic psychedelic use. There is potential for mutually beneficial partnerships for these two domains of research. 

Relevance to our mission and vision: It is part of our mission to develop effective learning systems that benefit those we serve. We also aim to serve people with a varied set of skills, some of them with complex verbal repertoires. Moreover, many of the people who will receive our services will be faced not only with a learning or developmental disability but also with some form of psychological suffering. Understanding the development of language, first and foremost, and the impact it can have psychologically (both good and bad) is imperative to our mission. Understanding ACT and the psychological flexibility model can lead us to assessment and intervention systems that can alleviate psychological suffering for people-served, their support teams, and our staff. 

Relevant iASK Skills Domains: Complex Verbal Behavior, Committed Action