The Ethical Obligations, Barriers, and Solutions for Interprofessional Collaboration in the Treatment of Autistic Individuals

Abstract

With an estimated 1 in 44 children having been diagnosed with autism and given the variety of types of service providers that treat autism, collaboration among these professionals is a necessary part of the overall treatment package for an autistic individual. However, like with any professional skill, competence in collaborating effectively must be developed, especially because behavior analysts have been criticized for being resistant to collaboration. Competence with collaboration may be developed through coursework, professional development opportunities, and supervision by someone who has demonstrated competence with collaboration. With the 2020 update to the Ethics Code for Behavior Analysts, the behavior analyst’s role in collaborating with other professionals has been clarified by several expectations. Current literature also provides additional guidance on the potential barriers to collaboration as well as recommendations for how to support a collaborative team. In order to facilitate successful collaboration, it is also important to evaluate the effectiveness of the collaborative team and to take advantage of opportunities to learn about the methodologies and perspectives of the other professionals to ensure that the client’s best interests are met.

The Centers for Disease Control and Prevention (CDC) have estimated that 1 in 44 children have been diagnosed with autism (Maenner et al., 2021). Common service providers that work with autistic individuals include speech and language pathologists (SLPs), psychologists, mental health counselors, occupational therapists (OTs), physical therapists, special education teachers, behavior analysts, physicians, nutritionists, social workers, and nurses (Cox, 2012; Strunk et al., 2017). With so many professionals involved in the treatment of autism, collaboration is not only unavoidable, but also an essential component of providing these services (Bowman et al., 2021; Gasiewski et al., 2021). For example, Kelly and Tincani (2013) reported that among respondents of a questionnaire that included behavior analysts, teachers, psychologists, and school psychologists, 62% indicated that they collaborate with other professionals at least daily. Moreover, the World Health Organization (WHO, 2010) described the purpose of collaboration as delivering the highest quality of care. The work that a collaborative team can accomplish together provides an opportunity that may not exist with each professional acting independently (Bowman et al., 2021; Bronstein, 2002; Cox, 2019). By combining the strengths of the various professionals, a collaborative treatment team is better positioned to maximize client outcomes together (Lindblad, 2021).

It is important to note that there are three primary terms that are commonly used to refer to collaboration among professionals, and though these terms are sometimes used interchangeably within research and practice, together they form a spectrum of collaboration that varies from being autonomous to interdependent (Bowman et al., 2021; Slim & Reuter-Yuill, 2021). The multidisciplinary approach involves professionals working in parallel on discipline specific tasks with limited communication and coordination among each other. In an interdisciplinary approach, professionals coordinate tasks, communicate often, and work toward shared goals while operating within their discipline-specific roles. Finally, a transdisciplinary approach focuses on forming an integrated expertise and unified treatment plan that blends across roles and disciplines of team members. At present, there are a variety of definitions for each of these terms, which can create confusion and disagreement regarding their intended purpose. Therefore, for the purposes of this discussion article, interprofessional collaboration will be used to describe the collaboration among the various professionals who practice any of the disciplines that provide services to autistic individuals.

A review of the literature showed that collaboration in general may be defined in a variety of ways depending on the people involved and their purpose. Kelly and Tincani (2013) explained that there is no standard definition of collaboration in terms of the interactions between professionals from a variety of disciplines, and as a result these disciplines have conceptualized collaboration differently. Effective collaboration with other service providers as part of a treatment team requires that team members must first clearly define collaboration regarding how the team can best meet the needs of the client. Montiel-Overall (2005) defined collaboration as “a trusting, working relationship between two or more equal participants involved in shared thinking, shared planning and shared creation of integrated instruction” (p. 150). Elements of collaboration often include the joint development of a common set of client-centered goals, a shared responsibility of achieving these goals, the flexibility to compromise and accept new ideas, a readiness to listen, a reflective evaluation of the collaborative process, a willingness to accept feedback, and a nonjudgmental use of each team member’s expertise as equals to meet these goals (Bronstein, 2002; Montiel-Overall, 2005; Welch & Tulbert, 2000). The purpose of collaboration is that each team member benefits from these interactions (Clark et al., 1996) and ultimately the client benefits from a higher quality of care provided by the combined expertise of the team members.

It is important, however, to denote the difference between collaboration and consultation. Participants are equals within collaboration, and all members receive mutual benefit toward meeting goals with a common client. In contrast, within consultation, a professional (i.e., the consultee) seeks the support and expertise of another professional (i.e., the consultant) to increase their own capacity to provide services to a client within their setting (Erchul & Sheridan, 2014). There are times that a consultative approach is needed as part of the overall collaborative process. Kelly and Tincani (2013) described this as a collaborative-directive approach using the example of a teacher with limited behavioral training that may need a more directive approach from a behavior analyst; however, the behavior analyst would first gain a list of the teacher’s top concerns within their classroom and then seek the teacher’s feedback on how likely any suggested behavioral interventions can be implemented within the classroom setting before collectively agreeing upon an intervention plan. They also reported a variety of modes in which collaboration may occur, noting that 98% of professionals surveyed indicated that they collaborated face-to-face, 91% through email, 71% through phone, 27% through texting or instant messaging, 11% through video chat, and 3% through blogs.

Based upon the Behavior Analyst Certification Board’s (BACB; 2020b) Ethics Code for Behavior Analysts, behavior analysts have one primary code that addresses collaboration with other professionals outside of the field of behavior analysis as well as two additional codes that mention collaboration. In Code 2.10 Collaborating with Colleagues:

Behavior analysts collaborate with colleagues from their own and other professions in the best interest of clients and stakeholders. Behavior analysts address conflicts by compromising when possible and always prioritizing the best interest of the client. Behavior analysts document all actions taken in these circumstances and their eventual outcomes. (p. 11)

Likewise, in Code 3.16 Appropriately Transitioning Services, behavior analysts are directed to collaborate with relevant providers when transferring clients to reduce disruptions to services. Finally, in Code 6.06 Competence in Conducting Research, when conducting research outside of their current competence level, behavior analysts are directed to collaborate with other professionals who have demonstrated expertise in that area. However, based upon the noted definitions of collaboration and consultation above, the authors of this article interpret Code 6.06 to mean consultation rather than collaboration due to the reference of the need for a behavior analyst to obtain appropriate supervision and training from someone who has the required competence that the behavior analyst seeks.

In addition to outlining the responsibility for working with colleagues, several other key ethical points from the Code must be considered when collaborating with other professionals. These ethical considerations include gaining informed consent from a client’s parent or legal guardian before disclosing confidential client information to other professionals, making appropriate efforts to involve stakeholders when selecting goals, relying on behavioral principles based upon scientific evidence when making professional decisions, and operating within the boundaries of one’s competence (BACB, 2020b).

Although behavior analysts must be competent in their abilities to collaborate, learning how to collaborate is not typically included in pre-service and in-service training for behavior analysts (Brodhead, 2015). This limitation poses a difficulty for the field of behavior analysis in which behavior analysts initially may not be prepared to collaborate with other professionals upon becoming certified. Without a basic background in interprofessional collaboration, many new professionals may be left to seek and develop collaborative skills on their own before demonstrating competence (Lindblad, 2021), which may not provide them with the necessary experience to participate effectively on a collaborative team.

The purpose of this article is to discuss how behavior analysts and students of behavior analysis can best meet their ethical obligations for engaging in more effective collaboration with other professionals as part of a treatment team for autistic individuals. Collaboration is not only unavoidable, but essential for maximizing client outcomes. Therefore, this article provides recommendations for meeting these ethical obligations by clarifying expectations and obligations in regard to collaboration as outlined by the current ethics code, identifying how to gain and increase competency in collaborating with other professionals, identifying barriers and potential solutions to facilitate effective collaboration, evaluating the effectiveness of the collaborative team, and by recommending areas for future research about collaboration. In this discussion article, we will specifically focus on interprofessional collaboration among behavior analysts and professionals outside of the field of behavior analysis that provide services to autistic individuals. Due to the scope of this topic, we will not address collaborative practices between behavior analysts and their supervisees as this is indicative of consultative relationships as opposed to a collaborative relationship among equals. In addition, we will not address collaboration among professionals conducting research as this form of collaboration falls outside of typical service provision models. This discussion article is intended as a guide for behavior analysts and students of behavior analysis to supplement insufficient education and experiences for collaborating effectively with other professionals who provide services to autistic individuals. In addition, behavior analysts can use the recommendations within this article to identify areas of need and create a plan for acquiring necessary competence in collaborative practices as a member of an effective interprofessional team.

Ethical Obligations in Preparing for Collaboration

Before collaboration with other professionals can begin, several considerations must be made. According to the BACB’s (2020b) Ethics Code for Behavior Analysts, behavior analysts must be knowledgeable about and comply with the ethics code. Therefore, before any behavior analyst begins collaborating with other professionals, a review of the ethics code must be completed. First, behavior analysts must be familiar with all relevant ethics codes that correspond to collaboration. Then, behavior analysts must examine their competence in collaborating with other professionals. Upon reflection, if a behavior analyst determines that they do not possess the necessary competence in collaborating with other professionals, the current literature has provided a variety of solutions for developing competency to resolve these deficits.

Within the introduction of the ethics code, several items help to set the tone within the profession of behavior analysis that collaboration is an expectation of ethical practice. The core principles are presented including that behavior analysts work to maximize benefits for their clients and to do no harm by effectively and respectively collaborating with others in the best interest of their clients (BACB, 2020b). In addition, behavior analysts ensure their competence by being aware of and remaining within their professional scope of practice and by frequently examining the boundaries of their competence. Finally, within the glossary, “collaborator” is listed as a stakeholder, which is defined as “[a]n individual, other than the client, who is affected by and invested in the behavior analyst’s services” (p. 8). Given this expectation for collaboration with other professionals, it is essential for behavior analysts and students of behavior analysis to familiarize themselves with the specific codes that outline the expectations of collaboration (see Table 1).

Table 1.

Recommendations for Collaboration Based on the Relevant Ethics Code

Code		Recommendation
Section 1: Responsibilities as a Professional
1.04	Practicing within a Defined Role	Define and document your role within the treatment team.
1.05	Practicing within Scope of Competence	Practice within your scope of competence, complete the necessary training and supervision to demonstrate competency, or refer the client to someone who is competent.
1.06	Maintaining Competence	Engage in ongoing continuing education and professional development opportunities about collaboration.
1.1	Awareness of Personal Biases and Challenges	Reflect on personal biases that may interfere with collaboration and consult with a colleague or supervisor to find resolutions.
1.15	Responding to Requests	Respond to information requests from stakeholders within timeframes that are consistent with your organization or industry.
Section 2: Responsibilities in Practice
2.01	Providing Effective Treatment	Prioritize interventions that maximize client outcomes, provide treatment consistent with behavioral principles, and implement nonbehavioral services with required training and credentials.
2.04	Disclosing Confidential Information	Share confidential information about clients when informed consent is obtained.
2.08	Communicating about Services	Use language that ensures that all stakeholders understand assessment results and interventions.
2.09	Involving Clients and Stakeholders	Make appropriate efforts to involve stakeholders when selecting goals, designing interventions, and monitoring progress.
2.1	Collaborating with Colleagues	Collaborate with other professionals, address conflicts by compromising when possible, and prioritize interventions that maximize client outcomes.
2.12	Considering Medical Needs	Obtain a medical rule out from a qualified professional to assess any potential medical or biological concerns before proceeding with a behavioral intervention.
2.16	Describing Behavior-Change Interventions Before Implementation	Describe behavioral interventions in writing before implementation, and explain the conditions needed for treatment success to the team.
2.18	Continual Evaluation of the Behavior-Change Intervention	When there is a conflict among treatments within a team, review the misalignment and work together to find a solution that maximizes client outcomes.
Section 3: Responsibilities to Clients and Stakeholders
3.01	Responsibility to Clients	Put aside personal biases and focus on the client's identified needs in order to maximize their outcomes.
3.02	Identifying Stakeholders	Identify the stakeholders and your obligations to each when providing services, and document and communicate these obligations to those stakeholders.
3.03	Accepting Clients	Accept clients whose needs fit within your scope of competence and what your available resources allow for, including time.
3.06	Consulting with Other Providers	Consult with other providers when approaching the boundaries of your individual scope of competence.
3.16	Appropriately Transitioning Services	Collaborate with other service providers when transitioning services in order to minimize disruptions to services.

The above table summarizes the current body of research regarding behavior analysts' obligations for collaboration with other professions based upon the BACB's (2020b) Ethics Code for Behavior Analysts

Develop Competence with Collaboration

Code 1.05 focuses on behavior analysts practicing only within their scope of competence (BACB, 2020b). In addition, before practicing in new areas, the behavior analyst must first study, receive training, receive supervision under, and/or co-treat with a professional who has training in that new area. It would be ideal if, before a behavior analyst can develop a collaborative relationship with other professionals, they first develop the skills necessary to be able to collaborate effectively. In practice, this may not always be feasible, so it may also be appropriate to gain competency concurrently with the collaborative opportunity. Given the various professionals who provide treatment to autistic individuals, this type of competency is recognized as a means to ensure that a client’s best interests are met across all of their services as well as to access better treatment outcomes (Cox, 2019; Donaldson & Stahmer, 2014; Gasiewski et al., 2021; LaFrance et al., 2019; White et al., 2018). In order to gain this competency, there are three primary paths that a behavior analyst can take: through coursework, through professional development, and through supervision by someone who has demonstrated competence in collaboration with other professionals.

Gaining Competence through Coursework

The coursework curriculum within behavior analysis graduate programs is based on the Board Certified Behavior Analyst Task List (5^th ed.; BACB, 2017) and the Board Certified Assistant Behavior Analyst [BCaBA] Task List (5^th ed.; BACB, 2020a). The Fifth Edition Task Lists mention “collaboration” within section H-9 for BCBAs and section H-8 for BCaBAs: “Collaborate with others who support and/or provide services to clients” (BACB, 2017; BACB, 2020a). Although collaboration is an expectation set out by the BACB for behavior analysts, Kelly and Tincani (2013) reported in their study that 67% of respondents indicated that they had not completed coursework with “collaboration” in the course title or description. Research within the field supports a need to increase collaborative coursework for behavior analysts, suggesting that they would benefit from having more training in collaboration during coursework (Boivin et al., 2021; Brodhead, 2015; Kelly & Tincani, 2013; Lindblad, 2021; Sinai-Gavrilov et al., 2019; St. Peter, 2013; Vyse, 2013). Sinai-Gavrilov et al. (2019) also argued for providing students with a basic background for working on interprofessional teams.

One approach to gaining competence with working on an interprofessional team is to learn about other professional perspectives. White et al. (2018) conducted a multiple baseline study involving interprofessional coaching with four graduate students: two from an applied behavior analysis (ABA) program, one from an OT program, and one from an SLP program. This integrated client care program coached the four graduate students through an FM receiver with core autism treatment procedures from the other professions. For example, the ABA student learned two skills from OT and two skills from SLP, and vice versa with the other graduate students from OT and SLP. The results of the coaching demonstrated an effective graduate interprofessional training package for students from ABA, OT, and SLP programs as each graduate student demonstrated mastery of the cross-trained skills (White et al., 2018).

In a more recent study, Boivin et al. (2021) described a program for training preservice behavior analysts to collaborate with other professions including speech-language pathology, occupational therapy, physical therapy, and developmental pediatrics. This training program used a combination of “selected readings, applied projects, pre- and posttests, and SAFMEDS [fluency flashcards]” (p. 1229) across 15 weekly modules. For example, several of these modules directed student analysts to select peer-reviewed articles from other professional disciplines and summarize their findings in order to develop a deeper understanding of evidenced-based practices from those disciplines. St. Peter (2013) also recommended that behavior analysts must expose themselves and their students to other perspectives, to listen to other professionals in order to learn about their perspectives, and to appreciate approaches that differ from their own. This process of learning through the perspectives of other professionals helps the behavior analyst to become a collaborative specialist.

Gaining Competence through Professional Development

Code 1.06 provides examples of professional development activities including “reading relevant literature; attending conferences and conventions; participating in workshops and other training opportunities; obtaining additional coursework; receiving coaching, consultation, supervision, or mentorship; and maintaining appropriate professional credentials” (BACB, 2020b, p. 9). Despite the availability of this variety of professional development opportunities, Kelly and Tincani (2013) reported that 45% of respondents indicated that they had not attended workshops with “collaboration” in the title or description. These findings indicate a need for more focused opportunities for behavior analysts for learning the skills to collaborate with other types of professionals through continuing education.

Gaining Competence through Supervision and Consultation

Given the apparent lack of focused learning opportunities about collaboration as part of coursework or through formal professional development, behavior analysts may also gain competence through supervision and consultation. In particular, Codes 1.05 and 1.06 list supervision, coaching, consultation, mentorship, and co-treating from professionals with demonstrated competence as additional ways to gain necessary competence in new areas of practice (BACB, 2020b). Just like with other professional practices, training in collaboration can also be obtained through the various forms of supervision and consultation, as noted above. Brodhead (2015) made the argument that if a behavior analyst is not adequately trained to provide services within an interdisciplinary team, then they should either seek proper supervision to gain competency or refer the client to another behavior analyst who does have those skills. For example, Bailey and Burch (2016) suggested gaining competence in a new area by spending several weeks at a site in which a new skill can be observed and practiced with feedback given on performance from a mentor. This path to gaining competence is supplemented with other approaches such as completing coursework, reading research articles, and attending professional development opportunities.

Gaining Competence through Cross Training

Coursework, professional development, and supervision and consultation are the recognized standard for gaining competence in a new area of practice within the field of behavior analysis. In regard to collaboration, behavior analysts have an additional path in which to gain competence: through cross training. Each profession trains its professionals with basic philosophical and epistemological assumptions that determine how they make decisions about which intervention to use and why (Cox, 2019). These professions are necessary in providing treatment to individuals because it is not humanly possible for any professional to be fully trained in all disciplines (Dillenburger et al., 2014). Each professional on a collaborative team possesses a unique set of skills that provides a different perspective to the team (Donaldson & Stahmer, 2014; Newhouse-Oisten et al., 2017), and each professional must recognize that they cannot meet all of the therapeutic needs of a particular client and must therefore rely upon the expertise of the other professionals on the collaborative team to differentiate treatment to meet the needs of the client (LaFrance et al., 2019).

Collaboration allows for professionals to learn more about other disciplines and to gain from the knowledge those disciplines bring to the treatment team (Cox, 2019). Other professionals’ use of alternative theories or philosophies does not make those professionals incompatible partners when it comes to collaboration and may in fact bring different perspectives that allow the team to be more effective in developing a comprehensive treatment plan (LaFrance et al., 2019). The benefits of cross training include gaining an understanding of the perspectives of other professionals and how they make their decisions when recommending nonbehavioral treatments (Brodhead, 2015). More important, understanding the research that supports nonbehavioral treatments may allow the behavior analyst to translate a treatment into behavior principles in order to better understand the treatment’s potential effectiveness as an intervention for the specific client. Slim and Reuter-Yuill (2021) argued that rather than rejecting mentalistic interventions, behavior analysts can translate other professionals’ terminology into behavioral terms allowing them to retain their place on the collaborative team.

Cross training can be as simple as conducting a review of seminal research from another profession’s treatments (Boivin et al., 2021; Brodhead, 2015; Gasiewski et al., 2021). Another form of cross training may be one professional educating the other collaborative team members on a proposed intervention by providing the purpose of the intervention, a description of the intervention, the desired effects, any potential side effects, and the degree of research supporting the intervention (Newhouse-Oisten et al., 2017). Also, Sinai-Gavrilov et al. (2019) explained that interprofessional workshops can provide collaborative team members opportunities to gain a deeper understanding of each other’s roles and address any misconceptions that might exist.

Facilitate Effective Collaboration

After a behavior analyst has gained competency in collaborating with other professionals, several considerations exist for engaging in collaboration. These considerations include barriers to collaboration, the limitations of ABA, and differences among service providers. The current literature has identified potential solutions to these barriers including qualities that make collaboration easier, alignment across disciplines, and ways to evaluate the effectiveness of collaboration.

Identifying the Barriers to Collaboration

Many barriers to collaboration have been identified among behavior analysts and other professionals. Some of these are structural barriers including organizational constraints (Strunk et al., 2017) and caseload size (Bronstein, 2002). In addition, collaborative teams may not be located within the same area or facility, which can limit communication and how regular collaborative opportunities may occur (Minshawi et al., 2015).

Another barrier is the limited availability of time (Bronstein, 2002; Cox, 2019; Donaldson & Stahmer, 2014; Minshawi et al., 2015; Sinai-Gavrilov et al., 2019; Strunk et al., 2017). For example, many professionals experience difficulty in scheduling time to communicate with others on a treatment team due to time constraints outside of sessions (Minshawi et al., 2015; Sinai-Gavrilov et al., 2019; Strunk et al., 2017). In order to collaborate as an effective treatment team, sufficient time to deliberate and make plans together is required (Sinai-Gavrilov et al., 2019). However, due to differences in the sizes of caseloads, some professionals may have less time to engage in collaborative practices. Depending on the severity of need, a client may receive up to 40 hours of ABA services per week, which helps to reduce the overall caseload for behavior analysts in comparison to other professionals that typically carry higher caseloads. For example, school-based professionals and other service providers such as speech language pathologists, occupational therapists, and mental health counselors often have large caseloads and must therefore use their time efficiently (Donaldson & Stahmer, 2014), which may make it difficult for those individuals to find adequate time to coordinate and collaborate with other professionals on the treatment team outside of their scheduled sessions.

Professionals may also encounter confusion of the roles and the responsibilities of different professionals (Sinai-Gavrilov et al.,2019; Strunk et al., 2017), differences in theory and methodology (Lindblad, 2021; Whiting & Muirhead, 2019), and the lack of a common language due to professional jargon (Arntzen & Vandbakk, 2014; Becirevic et al., 2016; LaFrance et al., 2019; Whiting & Muirhead, 2019). These barriers might be explained by a lack of cross training and exposure to other professionals that work with autistic individuals during the precertification phase and ongoing professional development. Strunk et al. (2017) noted “that there are a limited number of disciplines using an interprofessional, multidisciplinary approach when working with [autistic children]. These reasons include being discipline-based, organizational constraints, lack of training in the multidisciplinary approach, and fear of opposition” (p. 61).

There are also barriers within the more intrapersonal dimensions of collaboration such as the need for recognition of the value of one’s work, the fear of opposition, and avoidance of confrontation (Strunk et al., 2017). The skeptical nature of behavior analysts in questioning interventions may also be misinterpreted as questioning the validity of evidence-based practices from other professionals from different disciplines. Brodhead (2015) identified that excessive questioning from a behavior analyst may affect rapport and the collaborative relationship of a treatment team and in extreme cases may result in the behavior analyst’s exclusion from the collaborative team. Although it is important to maintain our skepticism when evaluating any intervention, it is equally important to note that being collaborative and being skeptical are not mutually exclusive.

Practicing with Humility

A common weakness among behavior analysts is their resistance in seeking outside perspectives (St. Peter, 2013). Using a questionnaire with a 5-point Likert scale, Kelly and Tincani (2013) reported that BCBAs were more likely to provide recommendations to another BCBA than to a non-BCBA, and that BCBAs are more likely to adopt a recommendation from another BCBA than from a non-BCBA. Results of their study indicated that collaboration among behavior analysts and other professionals tends to be a unidirectional process in which behavior analysts often provide recommendations without input from the collaborative team. Recommendations of this type more closely resemble consultation rather than collaboration and may further diminish the effectiveness of a collaborative team. These findings are concerning considering that if behavior analysts are providing recommendations without properly gaining input from other professionals, those recommended behavioral interventions are less likely to be implemented across settings, such as in a special education teacher’s classroom where clinical recommendations may be more difficult to implement.

Likewise, Becirevic et al. (2016) described behavior analysts as having a marketing problem in that their contributions to research are largely marginalized due to behavior analysts’ deliberate efforts to distance themselves from mainstream psychology. This distancing has its benefits in reducing problems down to what is observable and has helped to develop ways to understand and control behavior. However, due to the tendency of behavior analysts to advocate for behavioral interventions above others, behavior analysts sometimes become aversive to other professionals when disseminating these ABA evidenced-based practices. Walmsley and Baker (2019) advocated for behavior analysts to learn to evaluate evidence-based practices from other professions, which may in turn help to prevent colleagues from avoiding behavior analysts during collaborative opportunities and would satisfy the need for cross training. Further, Becirevic et al. (2016) reported that the side effects of isolation have led behavior analysts to research topics that are too narrow for the broader population and to use terminology that acts as a barrier to non-behavior analysts. They argued that “In the marketplace of human services, anything that makes them [behavior analysts] seem less warm and approachable—including the use of presumably unpleasant technical terms—might put them at a disadvantage compared to other kinds of service providers” (p. 307).

Another possible limitation within behavior analysis may be the historical trend to reject nonbehavioral interventions. For example, prior to January 1, 2022, the previous Ethics Code 8.01(b) stated, “Behavior analysts do not implement non-behavior-analytic interventions” (BACB, 2014, p. 16). As a result, behavior analysts have traditionally advocated for the implementation of only behavior analytic interventions when working on a treatment team because, as the previous Ethics Code 4.01 states, “Behavior analysts design behavior-change programs that are conceptually consistent with behavior-analytic principles” (BACB, 2014, p. 12). However, Brodhead (2015) made the argument that questioning nonbehavioral treatments or suggesting that an alternative behavioral treatment should be implemented, may be considered a noncollaborative practice. With the revisions to the Ethics Code for Behavior Analysts (BACB, 2020b), Code 2.01 emphasizes the need for behavior analysts to prioritize the rights and needs of their clients in the provision of effective and appropriate interventions as well as stating that behavior analysts may implement nonbehavioral services with clients when they have the required competencies. This change is a further confirmation of a shift within the field of behavior analysis from being overtly restrictive to recognizing the importance of collaboration in order to best meet the needs of the client. Given the recency of the implementation of the current ethics code, it is likely to take time for behavior analysts to universally adopt a more collaborative approach with other professionals.

Recognizing the Differences among Service Providers

Behavior analysts typically rely upon single-subject design methodologies when referring to evidence-based practices. However, other disciplines such as psychology and medicine might rely more on between-subject designs in which groups of participants are compared to different conditions (Cox, 2019). These different methodologies may serve as a barrier for professionals who are accustomed to interpreting the evidence offered by a particular methodology (Cox, 2019; Li & Poling, 2018). Just like with any other skill, behavior analysts must develop their competency by reading and consuming research using other methodologies or defer to the expertise of other professionals.

Another difference among the various service providers is the content of their ethics codes. Cox (2019) recommended that collaborative teams should be aware of the differences in the ethics codes across their various disciplines to understand the obligations, responsibilities, and professional practices of each member of the team. One set of ethics codes may not address a situation that could arise within other disciplines because that situation might not be relevant to a particular discipline or it may fall outside of their scope of practice. However, those professionals must be aware of these differences in other ethics codes because another professional may not have any guidance for how to proceed or what to be aware of in those situations. Various disciplines may also be held accountable at differing levels for complying with their ethical codes. For example, some professionals are licensed within a state and are therefore bound by their specific state’s laws. Whereas other disciplines within that state may only hold a certificate and are only bound by the requirements of a certification board. Therefore, a certificant is not necessarily held to the same obligations and legal consequences as a licensed professional, and they may not view the consequences of their professional decisions in the same manner.

However, a difference of professional opinion on what the client needs may result in conflict due to a discipline’s perspective on what is needed to maximize beneficence. “These differences are likely to occur across three areas: what a practitioner is targeting through a treatment; how they are planning to implement a treatment; and why a treatment has been chosen among available alternatives” (Cox, 2019, p. 50). Cox (2019) also explained that differing professions’ ethical codes may conflict with each other during this decision-making process. Helping professionals all have at least one goal in common: help the client. He further explained that it is important for members of a collaborative team to remind themselves that they are all there to improve outcomes for the client and to focus on how they can all benefit the client together.

Treatments from other disciplines may also contradict each other and therefore may pose as a barrier to beneficial outcomes in overall treatment for the client (Cox, 2019). For example, it is common for doctors to prescribe medication to address behavioral concerns in children (Li & Poling, 2018). However, Newhouse-Oisten et al. (2017) noted that the side effects of a medication may affect the effectiveness of interventions implemented by other professionals. For example, if a medication change occurs after a behavior analyst has conducted a functional analysis of a behavior, the change in medication may result in a change in function of behaviors and the selected interventions may no longer be effective.

Implementing the Solutions for Barriers to Collaboration

Cox (2019) reported that if multiple professionals are giving caregivers contraindicated treatment recommendations, treatment fidelity is also likely to suffer. He went on to suggest that the treatment team must remember to include the client within the decision-making process. Conflicts among a collaborative team may be resolved by referring to the client’s, or their legal guardian’s, treatment goals. This supports Mellin et al.’s (2010) emphasis that the collaborative team must remember the role of the caregivers in making progress toward collaborative goals.

Cox (2019) recommended that several proactive strategies could be used to decrease the likelihood of conflict from occurring by establishing routines for collaborative team members to communicate more effectively. One proactive strategy is to foster jargon free communication (Arntzen & Vandbakk, 2014; Boivin et al., 2021; Cox, 2019) and to modify language to match the listener (LaFrance et al., 2019). For example, developing middle level functional terms can provide more accessible language to professionals on the collaborative team to discuss common concerns (Becirevic et al., 2016; Greenwald et al., 2015; Vilardaga et al., 2009). Behavior analysts already use some of these words such as “attention” and “aggression” (Vilardaga et al., 2009). Becirevic et al. (2016) suggested that collaborative conversations require a mutually acceptable and understandable terminology.

A second proactive strategy is to develop a collaborative structure in which frequent interactions of team members are planned in order to foster coordination of services and to develop a formal relationship with each other as a treatment team (Cox, 2019). Several structural supports may facilitate collaboration including having a small caseload, an organizational culture that supports collaboration, administrative support, having the time and space available for collaboration (Bronstein, 2002), opportunities to interact and share clinical experiences, shared planning, debriefing opportunities (Strunk et al., 2017), regular discussions and planning across professions, prioritizing dialogue (Sinai-Gavrilov et al., 2019), continuous monitoring of collaboration, analysis of collaboration, revision of collaborative practices (Cox, 2019), and a setting that reinforces and maintains collaboration (Dillenburger et al., 2014). It is also vital for organizations to allow for time outside of billable hours for collaborative team members to plan, conduct observations, and manage other duties that may not otherwise be funded (Sinai-Gavrilov et al., 2019) because coordination of care is not often well-reimbursed (Strunk et al., 2017), if at all.

Once a collaborative team forms, regular communication must be established (Newhouse-Oisten et al., 2017). This communication may take a variety of forms including regular meetings of the entire collaborative team, one-on-one meetings among members of the team, or even an email thread that updates whenever an intervention changes with any professional (Newhouse-Oisten et al., 2017; Sinai-Gavrilov et al., 2019). In addition, Cox (2019) suggested that regular communication may help individual practitioners to begin to view their work as a team.

Cox (2019) also explained that developing an interprofessional environment helps to create respectful communication that can then be used to identify potential disagreements and resolutions before problems occur. Collaborative team members can facilitate team members’ feeling respected by recognizing and using the unique knowledge and skill sets of each member (LaFrance et al., 2019). Being able to voice one’s opinion and to be heard by other team members is an important part of perceiving oneself as a significant part of a collaborative team (Sinai-Gavrilov et al., 2019). Communication among professionals must be active and continuous in order to allow each team member to voice their concerns (Cox, 2019). Several practices can be used to allow collaborative team members to feel heard and valued, including active listening, engaging in dialogue, and reflecting upon another’s point of view (LaFrance et al., 2019).

Also, transparency in understanding each other’s philosophical assumptions as well as each other’s scope of practice can help to assist with team members implementing each component of the interventions decided upon by the treatment team (LaFrance et al., 2019). Cox (2019) recommended that collaborative teams could improve their collaboration and conflict negotiations by reframing their discussions around what they have in common as professionals while also remembering their differences in their obligations to their ethics codes and their professions. Likewise, collaborative team members should perceive new ideas from another discipline’s perspective as suggestions as opposed to attempts to undermine one’s discipline (Whiting & Muirhead, 2019). It is equally important to note that not all interventions work for all children, and an individualized treatment plan must be developed for each client (Whiting & Muirhead, 2019).

A third proactive strategy is to develop guidelines for collaboration and a common code of ethics that everyone can operate under (Cox, 2019). Likewise, Bowman et al. (2021) proposed a set of standards across professional disciplines in order to provide beneficial treatment to autistic individuals, which include collaborative communication, distinguished roles in collaboration, role of the organization, client care, conflict resolution, joint partnerships, evidence-based practice, and collaborative culture. These standards can be used as a guide for developing norms for interactions within the collaborative team as norms must be determined for how decisions are made, such as “does majority rule? Does the lead teacher consider members’ suggestions but still make the final decision? [and] Is evidence-based practice always prioritized?” (Sinai-Gavrilov et al., 2019, p. 4643). Also, when selecting an evidence-based practice, each professional must define what their profession calls strong evidence as this may differ among professions (Cox, 2019).

When the inevitable happens and conflict arises within the collaborative team, Cox (2019) suggested several reactive strategies for resolving this conflict. The first reactive strategy is to refer to the agreed upon guidelines and ethics codes that the collaborative team developed as part of the proactive strategies to avoid conflict. This shifts how the conflict is framed and ultimately back to agreed-upon client outcomes. Another reactive strategy is to take the opportunity to use the conflict to learn about each other’s professions as well as to take advantage of learning about new ideas from other professionals. Conflict has the potential to become a learning opportunity. Finally, institutional resources can be used to reach a conflict resolution, whether it may be additional training, feedback on performance, referring to institutional goals, or possible incentives to collaborate.

Cultivating the Qualities of Effective Collaboration

As discussed above, there are many barriers to collaboration and factors that may limit the effectiveness of that collaboration. However, the literature has described numerous qualities that may support collaboration and help to make that collaboration easier. These qualities include valuing and being respectful of professional opinions from other disciplines (Brodhead, 2015; Bronstein, 2002; Cox, 2019; LaFrance et al., 2019; Mellin et al., 2010; Sinai-Gavrilov et al., 2019; Strunk et al., 2017; Whiting & Muirhead, 2019), being open minded to other disciplines (Sinai-Gavrilov et al., 2019), valuing the unique perspectives of team members (Strunk et al., 2017; Whiting & Muirhead, 2019), understanding other professionals’ perspectives (Brodhead, 2015), understanding other professionals’ roles (Cox, 2019; Sinai-Gavrilov et al., 2019), appreciating the science behind other disciplines (Brodhead, 2015), proactive and regular communication (Cox, 2019; Newhouse-Oisten et al., 2017), time spent together or having a shared commitment of time (Bronstein, 2002; Strunk et al., 2017; Whiting & Muirhead, 2019), shared decision making (Mellin et al., 2010), flexibility to compromise during disagreements and having flexibility with roles and responsibilities within the team (Bronstein, 2002; Mellin et al., 2010), coordination and cooperation (Whiting & Muirhead, 2019), having common goals (Strunk et al., 2017), collective ownership of goals (Bronstein, 2002); interdependence on each other to accomplish goals and maintain treatment protocols (Bronstein, 2002; Cox, 2019; Mellin et al., 2010), a sense of shared responsibility (Strunk et al., 2017; Whiting & Muirhead, 2019), a sense of purpose (Strunk et al., 2017), and mutual trust (Bronstein, 2002; Sinai-Gavrilov et al., 2019; Strunk et al., 2017; Whiting & Muirhead, 2019).

Brodhead (2015) argued that by promoting desirable professional interactions, behavior analysts will earn trust and partnership from other professionals and help others to recognize the field of applied behavior analysis as being collaborative. The qualities that support collaboration can help to mitigate the effects of the barriers that may disrupt collaboration. For example, there are times that a behavior analyst may need to advocate for avoiding a nonbehavioral treatment, such as when controversial treatments place time constraints on when evidence-based treatments may be implemented. Effective collaboration may occur when the team fosters the established qualities listed above and are able to find a collaborative solution through compromise. As an alternative, Newhouse-Oisten et al. (2017) noted that if one evidenced-based treatment is incompatible with another evidenced-based treatment, then the collaborative team must determine which one to implement first.

Bronstein (2002) explained that a collaborative team may hold collective ownership of their shared goals and, with it, a shared responsibility to the client’s best interest. However, each professional must also take responsibility of their own successes and failures with the client and their colleagues in working toward these shared goals. This responsibility to the success of the team, and ultimately the client, necessitates developing interdependence as a collaborative team and relies upon all members to accomplish the goals and tasks set by the team. In addition, if members of a collaborative team can provide emotional support to each other to counteract the stress and tension that is part of their roles and the work that they do (Sinai-Gavrilov et al., 2019), they can more easily foster the qualities that will enable them to collaborate more effectively.

Aligning the Practices of the Collaborative Team

Cox (2019) recommended that a collaborative team should focus on what they have in common with each other as members of a single group rather than as individuals from several other groups (i.e., different professions). Similarities do exist among disciplines, such as that behavior analysts and speech language pathologists both work on developing communication and social skills (Donaldson & Stahmer, 2014). Occupational therapists and behavior analysts both work on self-care, motor skills, and play skills (Whiting & Muirhead, 2019). In addition, there are fundamental ethical principles found across most helping professions (Cox, 2019). For example, respect for autonomy is something that is valued for clients by obtaining their informed consent before implementing treatment and by giving a client choices.

Cox (2019) claimed that other similarities among disciplines include nonmaleficence as a common ethical principle in which the professional has the obligation to avoid harming others or to minimize that harm when it is unavoidable. When there is a concern that a treatment may cause more harm than another, he recommended viewing any disagreements about the treatment in terms of nonmaleficence in order to better align with every professional’s obligation to do no harm. In addition, beneficence is a common ethical principle in which professionals must engage in practices that benefit the client. He suggested reminding other professionals in a collaborative team that they are all working toward this principle and that any conflicts are most likely the result of disagreements on how this principle can best be accomplished and measured.

Evaluating the Effectiveness of the Collaborative Team

When working as a collaborative team, all interventions must be evaluated as a whole, as opposed to each professional tracking their own interventions individually (Newhouse-Oisten et al., 2017). However, individual professionals may attend to their own collaborative contributions as part of reflective practice. Moreover, they can seek feedback from others in regards to their working relationships and the overall effectiveness of the team to meet the client’s needs (Boivin et al., 2021; Bronstein, 2002). In order to assess this effectiveness, Bronstein (2002) created the Index of Interdisciplinary Collaboration (IIC) as an instrument to measure the extent of collaboration between social workers and other professionals, and she also suggested that the IIC could be adapted for use with other professions. In fact, Mellin et al. (2010) revised this tool to develop the Index of Interprofessional Team Collaboration for Expanded School Mental Health (IITC-ESMH).

Mellin et al. (2010) described four factors that assess the functioning of an interprofessional team. First, reflection on processes allows for teams to evaluate how they work together and provide feedback to each other to support their continued collaboration. Second, professional flexibility describes how open professionals are to new ideas and the ways they ensure that they are valuing and respecting their collaborative teammates. Third, the creation of new professional approaches and strategies may allow professionals to deliver services and programs that may not have been possible if each profession worked independently and may lead to the generation of new professional practices. Finally, role interdependence involves the extent to which other professionals need each other to accomplish an intended goal or activity.

As another tool, Goreczny et al. (2015) developed the Team Process Assessment (TPA) to measure a team’s dynamics and functionality across nine areas including whether team members are actively participating in identifying problems, generating ideas to solve problems, implementing the suggested strategies, developing goals that are measurable and relevant, focusing on positive practice approaches, being sensitive to diversity issues, respecting each other’s views when differences of opinion occurred, being respectful to consumers, and providing an overall rating of the team’s functioning.

Bowman et al. (2021) also developed an evaluation tool called the Standards Adherence Self-Assessment Checklist based upon their proposed standards for collaboration across disciplines. Using a 5-point Likert scale, this tool assesses areas including collaborative communication, distinguished roles in collaboration, role of the organization, client care, conflict resolution, joint partnerships, evidence-based practice, and collaborative culture. This reflective practice helps the behavior analyst and student analyst to draw attention to their current collaborative behaviors and to identify deficits and strengths as part of the process of determining one’s scope of competence with collaboration.

Furthermore, Luiselli (2015) suggested that a social validity assessment can also be used to judge the performance and contributions of other members of an interdisciplinary team. Based upon the BACB’s (2020b) Ethics Code for Behavior Analysts, behavior analysts already have the ethical obligation to seek feedback on their performance in providing supervision to supervisees. An argument, therefore, can be made that behavior analysts should also seek feedback on their performance in collaborating as a member of the collaborative team from the other professionals (Luiselli, 2015). Seeking this feedback on collaboration would align with the core principles of the code, improve relations with other professionals, and help the collaborative team to ensure the best outcomes for their mutual client.

Conclusion

With the many professions involved in the treatment of autism, collaboration is necessary and unavoidable. It is vital that all behavior analysts and students of behavior analysis recognize that collaboration with other professionals is essential for the successful treatment of autistic individuals. Behavior analysts are ethically obligated to gain competence with collaboration and to engage in collaboration as part of an effective treatment team. Behavior analysis is not the only treatment for autism, and practicing in isolation from other professionals limits successful outcomes to services and fails to meet a client’s right to effective treatment by leading to the misalignment of treatment goals across disciplines. Further, Cox (2019) explained that outcomes from collaboration may be considered beneficial when the client has progressed more with a collaborative team than if they would have received each therapy separate without the occurrence of collaboration. Without collaboration, individual service providers are likely to provide services based upon the philosophical assumptions and practices of their discipline alone. This situation may pose alignment issues among service providers when discipline-specific practices do not have logical coherence with each other (Vivanti, 2017).

Ultimately, effective collaboration is no simple matter and there is much to be considered before participating in a collaborative relationship. Behavior analysts must understand the ethical obligations involved in collaborating, ensure that they have the appropriate level of competence before collaborating, identify any possible barriers within a collaborative team, find solutions to any barriers that exist, and of course evaluate the effectiveness of the collaborative process. Failure to implement these recommendations may limit the potential for maximizing effective treatment for a client and may further serve to isolate behavior analysts from other professionals who treat autism.

One of the greatest barriers to collaboration, found in the Behavior Analyst Certification Board’s (BACB, 2014) Professional and Ethical Compliance Code for Behavior Analysts, has been resolved with the revisions to the BACB’s (2020b) Ethics Code for Behavior Analysts. In the former ethics code, several sections created difficulties for behavior analyst when attempting to collaborate with professionals from other disciplines. For example, behavior analysts were previously required to only rely upon the science of behavior analysis and to cooperate with other professionals within the boundaries of being consistent with the philosophical assumptions and principles of behavior analysis alone (BACB, 2014, p. 4, 6). These former requirements have led some behavior analyst to become critical and demanding of nonbehavioral professionals and therefore aversive to them (Walmsley & Baker, 2019), which serves as a barrier to collaboration with other professionals and to effective treatment for autistic individuals. Previously, in situations where nonbehavioral interventions were suggested within a collaborative team, behavior analysts may have found themselves at odds with their team members due to an ethical obligation to advocate for behavioral interventions. This obligation has contributed to a common notion that behavior analysts are not especially collaborative. However, under the BACB’s (2020b) revised ethics code, behavior analysts are now afforded the flexibility to be more collaborative with the ability to compromise in circumstances in which a nonbehavioral treatment has been determined by the treatment team to best meet the needs of the client.

Given the prevalence of autism and the variety of professionals involved in its treatment, collaboration is necessary to ensure that the clients’ best interests are met. Gasiewski et al. (2021) further supported this, noting:

The outcomes for the individuals who are served will be more meaningful if expertise is collective, contributions across disciplines are respected, and we work to create environments in which the effectiveness of our procedures is augmented by contributions from other disciplines. (p. 1219)

Perhaps, the recent revisions to the ethics code will serve to remove some of the stigma and hesitancy that behavior analysts have historically felt toward collaborating with other professionals.

Behavior analysts and students of behavior analysis can become effective collaborators by developing their competence through coursework, professional development, supervision and consultation, and cross training. Once competency has been demonstrated, behavior analysts can more effectively facilitate collaboration by identifying the present barriers within a treatment team, practicing with humility, and recognizing the differences among service providers from other professions. Furthermore, collaboration can be optimized by implementing identified solutions to barriers, cultivating the qualities of effective collaboration, aligning the practices of the collaborative team, and evaluating the effectiveness of the collaboration.

Based upon the current review of the literature, we recommend that program directors and professors within behavior analytic programs either develop a course within the approved course sequence about collaboration or coordinate with another program within the college or university that already has a course developed about collaboration. A further recommendation for students of behavior analysis that do not currently have a course about collaboration within their program is to take advantage of an opportunity to complete a course about collaboration from another program if their program allows for a free elective. In addition, as part of cross training, students may benefit from the opportunity to take introductory level courses from other professions that work with autistic individuals such as education, mental health counseling, social work, speech language pathology, occupational therapy, etc. If students do not have a free elective available in their program, they may petition to gain permission to add a course to their program. Such experiences have the potential to increase the student analyst’s ability to understand and better collaborate with other professionals as a member of a collaborative treatment team.

Behavior analysts who did not have the opportunity to take a course about collaboration should consider completing a course as part of their professional development. As an alternative, behavior analysts may also search for sessions about collaboration offered at professional conferences or search for online professional development opportunities about collaboration. Additional opportunities for professional development may be gained by attending conferences in other related professions that work with autistic individuals such as the Council for Exceptional Children, the American Counseling Association, the National Association of Social Workers, the American Psychological Association, the American Speech-Language-Hearing Association, the American Occupational Therapy Association, etc. Although attending these alternative professional development opportunities may not yield continuing education units (CEUs) necessary for recertification within behavior analysis, they can provide unique and beneficial learning experiences that will aid behavior analysts in increasing their competence in collaboration. It is important for all professionals to recognize that there is more inherent value to professional development than merely gaining the necessary CEUs to recertify.

Although the above recommendations can provide a stronger foundation for developing and participating in collaboration, additional research is necessary to further enhance and promote more effective engagement in collaboration from behavior analysts. Strunk et al. (2017) noted that in the field of behavior analysis, and specifically within behavior analytic journals, there is limited research on collaboration across disciplines that work with autistic individuals. As collaboration with other disciplines becomes more prevalent, behavior analysts may need to consider the value of other research methodologies in answering research questions about collaboration that single subject designs may fail to conceptualize. For example, qualitative research could provide greater depth of understanding about the perspectives of a variety of service providers regarding the effectiveness of collaboration, uncover implicit or inherent biases that may prevent behavior analysts from effectively participating as a member of a collaborative team, and overall uncover nuance that single-subject designs inherently fail to provide. In addition, research is needed to examine several areas including an update to the prevalence of students completing coursework in behavior analytic programs, the degree of availability of professional development opportunities focusing on collaboration, the effectiveness of collaboration within an organization that provides services from multiple disciplines, collaboration of professionals from different organizations compared to within organizations, proactive strategies in fostering collaborative environments, and reactive strategies in resolving conflicts. Other areas include analyzing and identifying industry standards for caseloads for BCBAs and BCaBAs in order to better understand the organizational barriers that disincentivize collaboration with other professionals on the treatment team.

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Conflicts of Interest

The authors declare they have no conflicts of interest/competing interests.