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How Behavior Analysts Can Pull from Acceptance and Commitment Training to Promote Balance and Renewed Purpose

An Interview with Dr. Jonathan Tarbox

Why should we all be incorporating ACT into our daily practice, personally or professionally?

All humans spent way too much time and energy trying to avoid discomfort, and it gets in the way of doing what really matters – and that’s always true for everyone who has verbal behavior. Past the point of typically developing age of two or three, we all spend too much time talking to ourselves, worrying about stuff, and not enough time doing the stuff that actually matters. So basically, we’re hardwired for our minds to just get in our way, and ACT is a way to help decrease the influence of unhelpful thoughts and feelings, and unhelpful beliefs around uncomfortable thoughts and feelings. 

In behavioral terminology, it deals with rigid, ineffective rules: when I feel like this, I have to do that; or if I feel like this, I must do that. And it turns out, almost all of that is nonsense. It just isn’t helpful. 

It’s as though we’re all stuck with a best friend who’s always present, from the time we wake up until the time we go to sleep, and it always gives us unhelpful advice – like really, consistently gives us unhelpful advice - and is really, really pushy about it. We’re all born with that. So if that’s where we’re all at as humans, anything we can do to turn down the volume and decrease the power or effectiveness that our minds have over controlling our behavior can be helpful.

With that in mind, how do you envision a behavior analyst could transform their day-to-day practice by using ACT?

So basically, any behaviors or practices that the behavior analyst cares about, and thinks they can do better – if they’re a human being, there’s stuff that they’re thinking, and there’s stuff that they’re feeling, that’s getting in the way. So just start down the list of anything that you care about at work: being more present, being more open and more supportive of your staff that report to you, being more effective as a parent trainer, etc. Maybe it’s decreasing your own problematic behaviors, like calling in sick too often or showing up late for work, not turning in your time sheets on time, or gossiping, or being competitive when it’s not helpful or necessary. For any behavior you want to change that you care about at work, there’s something you’re thinking/feeling that’s getting in the way. 

So I actually think the better question is what could ACT not be helpful with in your daily practice as a behavior analyst? I mean, what do you have perfectly dialed in where you never mess up, and you’re just on it 100%. Nothing, right? We’re all human.

Okay, real talk. Here’s a reader-submitted question: how can we use ACT to deal with last-minute session cancellations. We’ve all been there. How can a behavior analyst serve all of their clients when there aren’t enough hours in the day as it is, and especially with real barriers such as last minute cancellations? How can they use ACT to help their practice in the face of these challenges? 

Yes! So that’s a common experience, right? For sure. So there’s really two different pieces. One piece is: is there anything I can really do to get parents to cancel less - would ACT be helpful with that? And the second piece is: is there anything I can do to be more effective, just given the current level of cancellations? 

For changing the parent behavior, definitely VALUES is the first thing that comes to mind, and COMMITTED ACTION. If the parent is cancelling a lot, there’s probably something difficult, irritating, frustrating – whatever – about showing up that’s getting in the way, or there are just other priorities in the parent’s life that are kind of trumping showing up for session. Values work could help them contact basically what they’re giving up for their children and their family by not showing up, and DEFUSION work helps people come into contact with the fact that their thoughts about how things shouldbe don’t need to control how things are.

So we’re all raised to believe if we feel hopeless or we feel to stressed out, we probably won’t do a good job, right? That’s what we all say – “oh yeah, I’ll do it when I feel better.” “I’ll get to the gym when I have more energy,” or “I’ll give that talk at a conference when I feel more confident.” I’ll do the behavior as soon as the private events or thoughts and feelings get right. And people give you that advice all the time: “All you have to do is believe in yourself and you can do anything!” As though the belief is what causes the actual behavior that matters. But defusion work just helps us come in contact with that fact, that what we’re thinking doesn’t need to control the choices that we make. 

So it’s Friday afternoon: a parent cancels, I can’t do it anymore, I feel like quitting. I still have a choice to make. My next two hours of my life are precious – they’re my two hours, it’s my life – what’s it about? Do I want it to be about avoidance and trying to make myself not feel crappy? Then okay, screw it – lie on your timesheet, or just go home or blow it off, or go get drunk, you know, whatever. But if you want to dedicate the next two hours of your life to make a difference in the world, maybe you could do that even when you feel like shit, or when you feel stressed out. It’s possible to get the job done even when you’re feeling like it’s not possible.

Do you have a favorite defusion strategy for that type of scenario, when you’re feeling like what you do isn’t working or it isn’t worth it? When you’re feeling those burn-out feelings?

Yeah, sure. One of my favorite ones is sarcastically thanking my mind for being so helpful. So if I have the thought “I can’t do this, I’m too tired”, then immediately respond to that thought (even out loud, if there’s no one around that’s gonna think I’m weird.)  I might say, “Wow! That’s so awesome, Mind. I really appreciate how you always know just what to say to really motivate me and really help me have a great day. That’s really awesome. Thanks for that.” And essentially what you’re doing there is you’re not honoring the idolized status that our whole society gives to the mind by kind of being silly at it, if that makes sense. 

When you were less fluent in this, or it was just a newer process for you, did you have a way of prompting yourself to get back in touch with your “WHY”, so that now that you’ve reclaimed those two hours, you can remind yourself what to do with them?

Yeah, for sure. So all the different values exercises. Imagine the first kid that you ever helped or made a difference for, or think about the first mom who really got it, where your behavior really made a difference for that kid. Remember the look in her eyes, the first time a parent teared up because she saw hope for her child; imagine that, remember that. Write down the name of that mom on a sticky note, stick it in the dashboard of your car, or fold it up, put it in your wallet. Before you walk into a house to work with a kid, take it out of your wallet, read it, close your eyes for 30 seconds, and imagine that kid and that mom, you know? Just simple, simple stuff like that. The thing is, you can’t just know about it; you have to actually do it. You can’t just remember “I know that values stuff, fine, whatever.” You have to actually take a second to walk yourself through that exercise. 

You’re essentially presenting stimuli to yourself. So you’re kind of treating yourself like you’d treat anybody else. Imagine if you present something really meaningful to someone else that affects their behavior in that moment. It’s the same thing with yourself. Except it’s not someone else, it’s you.  

Now that you’ve been teaching others to do this for so long, do you still use physical stimuli for yourself?

Yeah, I still do all that stuff. I’ll draw a matrix for myself. But then you do actually get more fluent, like you kind of just imagine it. I’ll visualize a matrix. I’ll think about it for a second. But yeah, that’s the cool thing: we’re never done learning; we’re never done getting better at this stuff. Even a Buddhist monk, who has been meditating for 30 years, still spends almost all of his time meditating. We’re always perfecting our practice. Whatever it is. That’s true with being a good behavior analyst, but it’s also true with taking care of ourselves.

On that note, can you speak to the present moment attention piece?

Yeah – Iet’s talk about the MINDFULNESS or present moment stuff. Learning to just notice what’s there, and try my hardest to see it for what it is, without judgement (or with as little judgement as possible), has completely changed my life. It has just made everything in my life better. It’s made my work better, has made me a better husband, better parent, makes me have more fun when I’m having fun. Just showing up for what’s there. Don’t take your mind so seriously. 

It’s easier said than done, but it’s practice. You just practice over and over and over. Every time I notice myself thinking something, I practice not taking it so seriously. Like even the things I really care about, even those things. They’re just things my mind is thinking. It’s really changed my life. 

I want to touch on balance. I think clinicians in our field are seeking true work-life-balance, and you have been such a model of that in so many ways, saying things like, “I’m not taking this opportunity because of my values, being home with my children and having quality time with them,” etc. You’ve spoken before about how it’s difficult to serve all of our values at once, how there’s more than one value at a time acting on any of us. So how do we balance going between our many values, since we only having so many hours in a day?

Well the standard ACT answer – and I’ll give you that (and I’m not even sure I agree with it) – but the standard one is: they don’t have to conflict; values should be kind of like the fingers on your hand. You have all of them; sometimes you can focus on one, sometimes the other. 

I kind of get that, but at the same time there only are so many hours in the day, and at any given moment when you’re choosing to do one behavior, you’re also choosing to not do other behaviors. So if you’re choosing to be at work, you’re choosing to not be with your family. If you’re choosing to look at your phone when you’re at home, you’re choosing to not look at your kids. If you’re choosing to do work instead of spending time with your spouse in the evening after the kids go to bed, you’re choosing work over your husband or your wife. 

And we all struggle with this, for sure. So I ask myself the question “What value is this in the service of” many times per day, every day. And every time I get an opportunity, I ask myself that question. And I’ve got a few rules that I do for myself that are really strict: one conference per month and one work trip per month. The other rule I have is 15 minutes a day on Facebook, period. I’m just not going to do more than that, even if I need to professionally; and then another rule I have is I don’t look at my phone or my laptop when my kids are awake, outside of work hours. So when the clock ticks 5 or whatever time is designated that day, laptop closes and that’s that. It doesn’t matter how important something is, I’m just not going to do it. And I probably disappoint a lot of people, and that’s okay; I’m willing to accept disappointing people, and I’m willing to accept feeling anxious and feeling anxiety, in the service of being the kind of dad I want to be. And when the kids go to bed, my rule is the laptop can open up, and I can look at my phone, but then the question is how much do I want to sacrifice my marriage? My wife is a totally kickass behavior analyst, works full-time also, has an amazing career, and so we struggle with that. And we want to spend as much time as we can with each other, and we have tons of work that we really care about and we want to do, so that’s a balance too.

But here’s the thing: what works for me isn’t going to work for other people, and it depends where people are at in their lives. Those rules work really well for me. And it’s funny, because it kind of doesn’t matter what I think about the rule, I just follow the rule. And so that’s the decision that I made for myself. And I don’t know if it’s the right thing or the wrong thing. I certainly don’t judge anybody else – ever – and I hesitate to even share these rules because it’s going to prompt people to judge themselves and maybe make them think that I’m judging them. I’m really not; it’s just what I’ve found to work for me. 

There’s nice literature on ACT’s ability to potentially help with feelings of burnout and we’ve talked about that a little bit. Do you ever find that using ACT so much almost contributes to burn-out? Do you ever feel that you’ve started to notice too fully, care too deeply, or that the stakes are so high every moment of the day that you maybe have to find a way to disconnect from that, or feel the need to run from that? Is that ever your experience, as a person who uses it so much, teaches it so much: have you ever felt that it’s all too much?

Such a good question. A really important principle in ACT work, and in all of behavior analysis, is pragmatism. Do what works; you don’t have to follow any rule past the point where it’s useful. It’s not like you have to do it all the time. If you’re holding onto it too tightly and insisting on it too much, you’re actually getting into fusion. So the ACT approach to doing ACT too much would be: chill out. Don’t do ACT so much. Think about the rules. That is doing ACT. Hold ACT lightly. Don’t take ACT seriously. That is doing ACT. So can you veg out and eat a whole bag of potato chips and watch Netflix for a few hours and say Eff the world? Of course. Every now and then. But it gets to the point where it’s not workable anymore and it’s having a negative impact, then dial back. 

And the same is true for whatever – talking about values. Chill out. Sometimes, just have fun. Don’t make everything a big deal. If you find you’re talking about values so much people are annoyed and don’t want to be around you, that’s too much! 

We haven’t hit that threshold yet.

I haven’t either, thank goodness.

Kristine Rodriguez, M.A., BCBA

Amidst the wealth of literature demonstrating ABA’s effectiveness [across multiple problems of social significance, though this article focuses on the provision of applied behavior analysis in the treatment of autism], the field is nascent in identifying a unified approach to measuring and reporting quality and outcomes. As the percentage of healthcare spend toward ABA increases nationally, payers are looking for increased accountability from providers. This includes internal monitoring for efficacy and compliance, as well as external reporting of the same.

As ABA works toward self-identification of pertinent quality metrics, a review of literature external to ABA is a helpful process to determining quality metrics currently adopted by healthcare broadly, and by mental health in particular. For the purpose of this article, guidelines provided by the healthcare literature, as well by the BACB’s Professional and Ethical Compliance Code for Behavior Analysts, are explored, and a package of quality metrics is proposed.

The problem is defined helpfully by Saver et al. (2015): measures that are arbitrary, easily measured, or that focus more on process than patient outcomes, family preference, and quality of life risk incentivizing poor care, gaming of the system, or creating an illusion of quality. 

Additionally, Saver (2005) and Baker & Qaseem (2011) make the following assertions: 

· Measures for financial incentive and external reporting should meet higher standards than internal improvement criteria 

• The methods used to develop a measure must be transparent to help stakeholders understand its validity and the expected health benefits of improving performance 
• [Providers] must develop more sophisticated measures that can be programmed into flexible, electronic, clinical decision-support rules 

Saver further expands upon these assertions by providing a practical framework for quality metrics, presented as core principles.

1. Address clinically meaningful, patient-centered   outcomes

2. Be   developed transparently and be supported by robust scientific evidence   linking them to improved health outcomes in varied settings

3. Includes   estimates, expressed in common metrics, of anticipated benefits and harms to   the population to which they are applied

4. Balance the time and resources   required to acquire and report data against the anticipated benefits of the   metric

5. Be assessed and reported at   appropriate levels; they should not be applied at the provider level when   numbers are too small or when interventions to improve them require the   action(s) of a system

For each of these core principles, further examination of literature and best practice resources (e.g. Practice Guidelines put forth by the BACB) leads to a discussion of treatment adherence. At the heart of patient-centered outcomes is analysis of patient satisfaction; in Autism treatment, this frequently translates to caregiver satisfaction. In addition to patient/caregiver satisfaction, literature suggests that effective outcomes are driven largely by treatment adherence. The literature further suggests that the same factors that improve treatment adherence improve patient satisfaction. Therefore, interventions to improve treatment adherence will likely affect both patient/caregiver satisfaction and program efficacy. Both are of chief importance to high-quality, effective programs, and therefore to healthcare funders. 

Consider the following from the literature on treatment adherence in healthcare (Martin et al, 2005).

· Quality healthcare outcomes depend upon patients' adherence to recommended treatment regimens 

· As many as 40% of patients fail to adhere to treatment recommendations; when preventive or treatment regimens are very complex and/or require lifestyle changes and the modification of existing habits, nonadherence can be as high as 70%

· Patient satisfaction and patient adherence are enhanced by patients' involvement and participation in their care.

· When health professional–patient relationships are mutual/reciprocal in decision-making, patients understand the costs and benefits of their recommended regimens, arrive at a better understanding of treatment, and achieve higher levels of satisfaction with the treatment encounter.

Additionally, involving family members and other caregivers in treatment planning and training them to implement certain components of the client’s treatment plan are important to promote carryover of treatment gains to times, people, and places outside of treatment (BACB, 2014).

These points highlight a number of opportunities to improve and measure quality within our field. These findings suggest that involving caregivers in the clinical decision-making process will improve their satisfaction and overall experience, as well as improve their adherence to difficult and complex protocols, likely leading to more effective outcomes for their child. Therefore, approaching solutions to treatment adherence in this way, by including the caregiver as a key member of the clinical decision-making team, is consistent with the Saver core principle of meaningful, patient-centered metrics. There are many researchers and practitioners disseminating important work in the area of compassionate caregiver training and involvement (see recommended reading); building upon that growing body of work will be critically important in effecting meaningful change for patients and families through improved treatment engagement. 

In reference to the principle of efficient and responsible balance of resources for acquiring and analyzing information, it is likely that ABA providers already pull a number of business-related reports that can be repurposed as quality assurance reports. These include: level of parent participation, delivery of authorized hours (contract/prescription fulfilment reports)/level of care reports, and caregiver satisfaction surveys.

Level of parent participation reports are required by several funders as a practice to ensure successively less restrictive service delivery, empowering families to provide meaningful generalization opportunities to their child, and reducing reliance on potentially intrusive 1:1 services over time. This report can simultaneously serve to gauge caregiver involvement in the treatment plan, as a measure to improve treatment adherence during and outside of scheduled session times.

Delivery of authorized hours (alternatively referred to as “prescription fulfillment” or delivery of service recommendations) suggests that the medically necessary level of care has been delivered as authorized. Although dosage response literature is still emerging in ABA, it may be presumed that in order for a patient to respond ideally to treatment, they need to receive the prescribed intensity of treatment. This report may be simultaneously analyzed to determined level of care recommendations are aligned with BACB practice guidelines for comprehensive and focused programs.

Caregiver satisfaction surveys should include questions that speak directly to the core principles proposed by Saver et al, inquiring whether the patient and family have experienced a significantly improved quality of life through receiving ABA services.

The final core principle addresses level of reporting. When outcomes are reported solely at the individual level, such as in re-authorization reports historically, there is greater opportunity for gaming of the system (in the case of incentivized pay agreements) or avoiding meaningful discussions of client progress, as the field has not yet defined how much progress is sufficient progress. Therefore, what the field needs most is aggregated reporting of client improvement over time, including dosage response data that factors for both intensity (i.e. hours per week, day, month) and overall duration, and across a large sample size. As randomized controlled trails are the gold standard in healthcare research, ABA studies may look to increasingly adopt that design to be wholly considered by funders’ physician panels. 

Ideally, multiple providers may explore pooling de-identified data in order to speak broadly to client response to ABA, as healthcare funders are accustomed to reviewing large data sets when creating funding guidelines. In the meantime, providers are encouraged to release the quality data they have available, in order to provide transparency to consumers and to move the reputation of ABA forward into the future of increasingly healthcare-funded services.

References

Bacb.com. (2014). Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers, version 2.0. [online] Available at: https://bacb.com/asd-practice-guidelines/ [Accessed 8 Apr. 2019].

Bacb.com. (2016). Professional and Ethical Compliance Code for Behavior Analysts. [online] Available at: https://bacb.com/ethics/ [Accessed 8 Apr. 2019].

Baker DW, Qaseem A, for the American College of Physicians' Performance Measurement Committee. Evidence-Based Performance Measures: Preventing Unintended Consequences of Quality Measurement. Ann Intern Med. 2011;155:638–640. doi: 10.7326/0003-4819-155-9-201111010-00015

Martin, L. R., Williams, S. L., Haskard, K. B., & Dimatteo, M. R. (2005). The challenge of patient adherence. Therapeutics and clinical risk management, 1(3), 189–199.

Saver BG, Martin SA, Adler RN, Candib LM, Deligiannidis KE, Golding J, et al. (2015) Care that Matters: Quality Measurement and Health Care. PLoSMed12(11):e1001902. doi:10.1371/journal.pmed.1001902

Suggested Reading

Taylor, B. A., LeBlanc, L. A., & Nosik, M. R. (2018). Compassionate care in behavior analytic treatment: Can outcomes be enhanced by attending to relationships with caregivers? Behavior Analysis in Practice.