When Cultural Awareness Reveals Conflicting Cultural Values: A Pragmatic Approach

Abstract

Cultural awareness reminds ABA service providers of the importance of considering the cultural practices of others when programming for behavior change. Decisions about the appropriateness of services may be difficult, however, when the values of the client conflict with the values of the culture(s) to which the client belongs or with the cultural biases of the practitioner. To minimize such conflicts, we propose a decision-making model that integrates client-centered and culture-centered assessments of habilitative validity. Throughout the proposed evaluation process, the behavior analyst and the recipients of services collaborate to refine program goals that will increase access to reinforcers for the client and their cultural groups. Given that cultures arrange reinforcers and punishers for the individual, assessing habilitative and social validity for the cultural groups affected by services is emphasized as an essential component of the model. We illustrate how the proposed model could be used to suggest appropriate courses of action by analyzing a situation that may involve conflicts of values.

In the last 10 years, the importance of cultural awareness has been frequently discussed among practitioners of applied behavior analysis (ABA; e.g., Beaulieu & Jimenez-Gomez, 2022; Brodhead et al., 2014; Dennison et al., 2019; Fong et al., 2016, 2017; Fong & Tanaka, 2013; Wright, 2019). Today it is widely accepted that acknowledging cultural differences and biases can positively affect the quality of the relationship between practitioners and consumers, and the success of behavior change programs (Brodhead et al., 2014; Fong et al., 2016). This commitment of the field towards increasing cultural awareness and responsiveness among practitioners, reflects the goal of ensuring that the best interest of the client remains the highest priority among providers of behavioral services. Such commitment is represented in the inclusion of cultural competency skills as a requirement for ethical practice (Behavior Analyst Certification Board, 2020).

A critical issue that has been examined less often, however, is how to make ethical choices about service delivery when there is conflict between the stated needs of the client and the values of the cultures to which the client belongs. Although enhanced cultural awareness may help the practitioner identify relevant cultural values, cultural awareness does not necessarily dictate the best course of action when the values of the client conflict with the values of a broader culture, such as a school, an organization, a religious group, or a community. For example, a school may advocate for eliminating stereotypy even though it may be a powerful reinforcer and preferred activity for the client. In such a situation, a conflict exists between the needs and preferences of the client and the values of the broader culture to which the client belongs. Although per the Ethics Code, practitioners are responsible for acting in the best interest of the client, this does not mean dismissing the impact of the intervention on the broader culture. In fact, positive outcomes for the client are not likely to result from declining to provide services when the values of the larger culture do not align with the preference of the client or intervening without consideration of the consequences for the culture. Because the broader culture arranges contingencies of reinforcement and punishment for the individual, courses of action should be more carefully considered.

To help practitioners determine what to do when conflicts between cultural values raise concerns about the direction of behavioral services, we suggest a decision-making model that guides the goal-determination process while mitigating existing conflicts of cultural values at the outset of services. Through this process, decisions regarding the selection of culturally relevant instructional practices are also considered, albeit indirectly. This model suggests a course of action when cultural awareness reveals conflicts of values regarding intended directions of behavior change. Following an analysis of the conceptual elements upon which the model is based, we illustrate its application by analyzing possible treatment outcomes for both the individual and the cultures of which he/she is a member.

Although cultures are commonly thought of as equivalent to racial or ethnic groups, from a behavior analytic perspective a culture is defined as a group of individuals whose shared verbal learning histories differ from those of other groups (Sugai et al., 2012). According to this definition, the term culture refers to groups of individuals that, in addition to ethnic groups, may include for example, families, religious groups, or groups who share a socioeconomic status, a sexual orientation, or a belief system. Individuals usually belong to several different cultures, some of which intersect or are part of larger, more encompassing ones. For example, an individual who is part of a family may also belong to a community of parents, be a behavior analyst, be a practicing Catholic, and be part of an Italian community. Further, culture membership is often fluid and variable, as individuals may join or leave various cultures across their lifespan. Consequently, the complexity of an individual’s behavioral repertoire is shaped by the contingencies established by multiple cultures operating simultaneously.

From an evolutionary perspective, cultural diversity is a natural outcome of the process of cultural evolution, which, paralleling genetic, epigenetic, and behavioral evolution, describes how cultural practices are acquired and transmitted through processes of variation, selection, and retention (Atkins et al., 2019; Glenn, 2004; Hayes & Sanford, 2014; Skinner, 1971, 1981). In other words, cultural diversity reflects the differences in the shared learning histories of different groups, and these differences result from selection processes operating both within and between cultures. On the other hand, cultural awareness refers to the ability to tact the behavior patterns of different cultural groups and the contingencies that maintain and influence those behaviors. Doing so also allows the individual to tact their own behavior as a product of culturally arranged reinforcement and punishment contingencies (Fong et al., 2016). This skill may be difficult to acquire however, when a person has limited contact with other cultures or when they have been reinforced for evaluating their own set of practices as standard, desirable, or better than the practices of other groups.

Such descriptions may exert strong control over a person’s behavior and impede cultural awareness. This may be particularly the case when rules are so culturally prevalent that the effectiveness, accuracy, or relevance of the contingencies those rules describe goes unquestioned. For example, although in some cultures it is customary for children to sleep with their parents for several years, in Western cultures it is recommended that children sleep in their own bed at an early age. A person from a Western culture may thus be likely to react negatively to a parent who co-sleeps with their toddler, and they may dismiss or invalidate their reasons for doing do. Likewise, views about expression of emotions that are considered standard and desirable in Western psychology, may not be positively perceived by individuals from other cultures. In some Buddhist cultures for example, cathartic emotional expression is prohibited or seen as barrier to healthy grieving or to overall wellness (Christopher et al., 2014). In both cases acceptance of these views depends on culturally acquired values. In addition, because rule-governed behavior is known to be characteristically rigid and resistant to change, exposure to contingencies that differ from those specified by the rule, is unlikely to decrease rule governance over behavior (Hayes et al., 1986; McAuliffe et al., 2014; Shimoff et al., 1981).

To illustrate, inevitably, individuals learn to refer to things they encounter in their daily lives as good or bad, adaptive or maladaptive, positive or negative. As verbal communities reinforce these categorizations, these evaluative descriptions inadvertently acquire truth status; that is, the verbal descriptions of those events are confused with the events themselves (Kantor, 1957). For example, a practitioner may label engaging in solitary play as problematic, inappropriate, or undesirable, and they may judge different types of parenting practices similarly. However, this practitioner may demonstrate cultural awareness by evaluating the extent to which they may be imposing on others what they have culturally learned to value as good or appropriate and by recognizing that other cultures may have developed different value statements. Thus, increasing cultural awareness involves recognizing that without exception, all cultural practices (including the person’s biases and value judgments concerning those practices) result from learning histories shared by particular verbal communities. By tacting not only the differences in cultural practices but also the histories of reinforcement that maintain those practices, practitioners may be able to recognize cultural values, including their own, not as universal or absolute, but rather as outcomes of particular learning histories.

The Impact of Cultural Awareness on Professional Practice

The impact of cultural awareness on professional practice has been recognized in other health related disciplines such as medicine, nursing, psychology, and social work, for decades (Wright, 2019). Extensive literature in these areas discuss notions such as illness and health, or suffering and well-being, in terms of social constructs inextricably related to an individual’s perceptions and cultural values, rather than as discrete categories with a fixed and universal set of referents (Christopher et al., 2014, Fisher-Borne et al., 2015; Nguyen et al., 2021). Furthermore, the use of these constructs in the applied sciences does not automatically make them objective or transcultural, as science itself is also influenced by pre-scientific views and cultural values (Christopher et al., 2014; Kantor, 1953). Across disciplines the general consensus is that it is an ethical responsibility for service providers to acknowledge that views about wellness, suffering, the desirability of a purpose-oriented life, the appropriateness social interaction, communication, or emotional expression, are culturally construed and cannot be dictated by science (Christopher et al., 2014). This recognition has been followed by specific standards to increase the practitioners’ responsiveness to cultural diversity. In clinical psychology for example, cultural competency guidelines that are now recognized by the American Psychological Association (APA, 2003, 2019) have been discussed for decades (Sue et al., 1982). Likewise, more than 20 years ago, the National Association of Social Workers (NASW) established specific parameters for culturally competent ethical practice, which are continuously revised and updated (NASW, 2015). In sum, recommendations for a culturally aware practice include self-evaluating biases and considering the complexity of intersectional influences (Hays, 1996), increasing cultural competence by gaining knowledge about diverse cultural practices, and using culturally adapted protocols and interventions with clients from diverse ethnicities (Rathod et al., 2018; Sanchez et al, 2022). Recent authors, however, have suggested that merely learning about other ethnicities or social groups could still lead to making decisions based on stereotypes (e.g., Fisher-Borne et al., 2015; Sanchez et al., 2022). The alternative is to develop strategies that allow the practitioner to learn from the client through every step of the therapeutic relationship. Thus, rather than increasing the practitioner’s cultural competence, which implies mastering a skill, current approaches suggest seeking to increase what Tervalon and Murray-Garcia (1998) called cultural humility. Doing so involves orienting the therapeutic relationship away from unidirectionality and authority, and towards a continued openness to learn about the things that are valuable to the client (Fisher-Borne et al., 2015; Gottlieb, 2021; Nguyen et al., 2021).

Even though research has shown that culturally adapted treatments are associated with improved treatment outcomes in clinical psychology (Rathod et al., 2018, Soto et al., 2018; Zane et al., 2016,), the strategies used are based on general assumptions about cultural groups and may fail to recognize the impact of intersecting cultural influences on the individual. Rather than using protocols adapted to different languages or seeking a provider of the same ethnicity as the client for example, Sanchez et al. (2022) proposes developing individualized assessment strategies that focus on how multiple group identities influence the client’s behaviors. Thus, cultural humility allows for an individualized integration of culturally informed assessment and intervention into every aspect of the therapeutic relationship (Nguygen et al., 2021).

Addressing the practitioner’s responsiveness to cultural diversity, has also a distinctive significance for applied behavior analysts given that, in determining the behavior-environment relations that lead to an improved quality of life, the terms appropriate and inappropriate, or desirable and undesirable, quickly become part of the practitioner’s habitual verbal repertoire. Yet, because what is considered appropriate or desirable depends on the reinforcers established by the culture, different cultures often arrive at different concepts of appropriateness or desirability.

For example, cultures may differ in the extent to which they value outcomes of behavioral intervention such as individuality, cooperation, social recognition, physical contact, and specific parenting practices. In particular, praise and recognition of individual achievements may be commonly seen as reinforcing in many cultures, but may be considered aversive in others (Christopher et al., 2014). Likewise, contingencies involving corporal punishment or withholding attention, may be considered acceptable in some cultures and cruel and inhumane in others (McIntyre & Silva, 1992). Such differences in cultural values have been widely researched among ethnic groups (see Forehand & Kotchick, 2016). Expressions of affection and physical contact for example, are more likely to be reinforcing for individuals from Hispanic cultures than for individuals from Asian cultures (McIntyre, 1992), and collaborative work toward common goals is more highly valued in Hispanic, African, and Asian cultures, whereas competing and working independently is typically reinforced in American and other Western cultures (Christopher et al., 2014; Forehand & Kotchick, 2016; Grossman, 1990). It is important to note, however, that although these general tendencies may be descriptive of reinforcement contingencies arranged by the members of specific cultural groups, within-group variations should be considered. Further, because an individual's behavior is under the control of contingencies established by the many cultures to which the person belongs, behavioral repertoires cannot be explained by understanding the contingencies operating in a single cultural group. Thus, although identifying a person as a member of a particular culture may provide valuable information to a practitioner, it should not inform clinical decisions in the absence of proper individualized assessment.

In addition to ethnic cultural identity, a client’s preference for a particular language is another cultural factor that merits consideration (Wang et al., 2019). Given that the stimulus functions of verbal stimuli are acquired culturally, differences in the functions of these stimuli may affect assessment and intervention outcomes. Instructions, prompts, and praise, when provided in a nonpreferred language, may have a different effect on a client’s behavior than when emitted in their native or preferred language (Brodhead et al., 2014; Dennison et al., 2019; Ripsoli et al., 2011). For example, challenging behavior may occur more often during instructional activities if instructions are delivered in a less familiar language or if the practitioner uses voice inflections or gestures that either are not part of the client’s verbal repertoire, or that have a different function in their preferred language. Thus, by failing to recognize the effect of language differences on the client’s performance (and overlooking functional differences in the verbal repertoires of speakers and listeners), practitioners may erroneously identify functional relations or choose the goals that best meet the needs of the client, inaccurately Dennison et al., 2019).

Thus, recognizing the impact that cultural differences have on the outcomes of clinical practice, behavior analysts have set forth recommendations for a cultural aware practice. Some of these include, considering client and stakeholder preferences in assessments and treatment, considering preferences regarding physical contact and other types of social reinforcers, obtaining approval and providing choices of teaching strategies, involving the client in all decisions related to assessment and treatment, and identifying personal cultural biases (Beaulieu & Jimenez-Gomez, 2022; Brodhead et al., 2014; Fong et al., 2016, Fong & Tanaka, 2013). In particular, when personal biases are recognized, practitioners are encouraged to observe their private behavior with respect to different cultural practices, to notice any judgmental reactions (Lillis & Hayes, 2007), to identify the learning histories behind those judgments, and to hypothesize the circumstances under which the actions of others have been reinforced by verbal communities (Friman, 2021).

These recommendations revisit the foundational view that the social significance of behaviors is determined by the consumers and communities affected by behavioral services. That is to say, it is consumers who define not only the behaviors to be targeted for change according to their priorities, preferences, and needs, but also the relevance and appropriateness of the behavior change programs (Wolf, 1978). The recent call for cultural awareness in behavior analytic practice is a reminder that social validity is much more than postimplementation satisfaction ratings measured in Likert scales. Social validity is the compass of the behavior analyst’s ethical guidelines.

When Values Conflict: A Pragmatic Approach

In keeping with social validity standards, professional development, research, and scholarly discussions emphasize the importance of strengthening skills that involve listening to clients' and stakeholders’ needs, considering their preferences, and involving them in the determination of goals, procedures, and outcomes (Bannerman et al., 1990; Schwartz & Baer, 1991; Wolf, 1978). Because cultural backgrounds often shape these preferences, awareness of cultural diversity further contributes to orienting behavior change interventions towards client-valued goals, procedures, and outcomes. In this context, one potential problem practitioners may encounter is how to make practical, sustainable, and ethical decisions about treatment when the values and preferences of the individual conflict with those of their culture or with the practitioner’s values. For example, in exercising cultural awareness, a practitioner might recognize they disagree with corporal punishment given their cultural background. Should they accept to include corporal punishment in the behavior change program if a family requests it? Similar conflicts of cultural values might be encountered when a homosexual teenager in a religious household has preferences that conflict with the family’s values, or when cultural groups have beliefs about gender roles or race that may diametrically oppose the views of the larger culture, or of the client him/herself. What should the culturally aware behavior analyst do if a family wants their son to behave more “manly,” or their underage teen daughter to have the skills of a “good wife?”

In these situations, practitioners may be tempted to evaluate which set of cultural values is right, better, or morally preferable, and they might do so based on their belief systems. A more objective solution cannot be made by appealing to a scientific analysis, however, because basic science is devoid of morality and cannot say which values are good or determine which outcomes are more or less desirable (de Melo et al., 2015). From a behavior analytic standpoint, values refer to things that are reinforcing or things that a particular culture calls good (Skinner, 1971, 1974). In particular, values are rules that alter the effectiveness of stimuli as reinforcers or punishers (Gould et al., 2018; Tarbox et al., 2020). As verbal evaluative statements qualifying things as good or bad, these verbal constructions are merely learned descriptions of the events, and not properties of those events.

However, although basic science is morally neutral, its application is not, and guidelines may be established to orient practitioners in situations wherein cultural values conflict. For example, although the knowledge produced by sciences such as nuclear physics, genetics, or behavior science is morally neutral, the use of that knowledge for particular ends involves ethical considerations. As a scientific and professional community, applied behavior analysts have committed to improving the lives of individuals and fostering their participation in their communities (Forehand & Kotchick, 2016). We suggest however, that accurately defining what it means to “improve people’s lives” and determining whose life should be improved in a situation of conflict (the client’s or their culture’s), will help determine whether the actions of the practitioner will advance or impede the intended outcome. A pragmatic approach involving evaluations of habilitative validity for society and individual provides an alternative to accomplish this goal.

Defining the Meaning of an Improved Life through the Lens of Habilitation

Hawkins (1986,1991) defined habilitation as the degree to which a behavioral repertoire maximizes long- and short-term reinforcers and minimizes long- and short-term punishers for the individual and their social environments. Although an evaluative analysis of the habilitative validity of behavior change programs is fundamental to behavior analytic practice, the outcomes that result in habilitation are often assumed as standard and only social validity is assessed. However, when cultural values conflict to the extent that the direction of service delivery is unclear, an objective way of determining whether an intervention would result in an improved life may be accomplished by evaluating with the client whether the suggested behavior change is likely to maximize the person’s ability to contact reinforcers and avoid punishers in the long and short term (Hawkins, 1991).

Although short- and long-term consequences should be considered in determining overall success, long-term changes should be given greater weight. In other words, interventions that increase long-term contact with reinforcers may be considered even if they also increase immediate aversive conditions for the individual. For example, if a person is highly anxious around dogs, a practitioner might use systematic desensitization to gradually expose the person to anxiety-inducing stimuli (i.e., pictures of dogs, videos of dogs, and eventually actual dogs). Despite an increase in aversive conditions in the short term, over time, an increase in reinforcement is likely as anxiety is reduced. On the other hand, an intervention that increases short-term reinforcement may be inappropriate if it also produces an increase in long-term punishing contingencies or aversive conditions. Allowing a person to avoid or escape aversive situations may be a preferred outcome for a client seeking to experience an immediate sense of relief. In the long-term, however, a strengthened repertoire of avoidant behavior may reduce opportunities for reinforcement. For example, allowing a child to opt out of mathematics instruction may reduce tantrums in the short term but decrease opportunities for academic success in the future.

Table 1 outlines the possible combinations of short- and long-term punishing or reinforcing treatment outcomes. The most optimal outcomes result in increased long- and short-term access to reinforcers and decreased contact with punishers (Tier 1). Less optimal (Tier 2) but potentially acceptable outcomes are likely to result in increased long-term access to reinforcers and decreased contact with punishers, even if there is a short-term decrease in reinforcement or an increase in punishment. Minimally acceptable outcomes (Tier 3) would involve interventions resulting in a short-term increase in reinforcement and decrease in punishment, and a long-term decrease in reinforcement or increased punishment. Finally, unacceptable outcomes (Tier 4) involve a decrease in short- and long-term reinforcement and an increase in short- and long-term punishment.

Table 1.

Possible short- and long-term outcomes of behavior change interventions

Outcome	Consequence Type	Short-term	Long-term
Tier 1: Optimal	Reinforcement	↑	↑
	Punishment	↓	↓
Tier 2: Mixed (Short-term Punishment)	Reinforcement	↓	↑
	Punishment	↑	↓
Tier 3: Mixed (Long-term Punishment)	Reinforcement	↑	↓
	Punishment	↓	↑
Tier 4: Unacceptable	Reinforcement	↓	↓
	Punishment	↑	↑

The goal of the practitioner—to produce changes that will result in an improved life—is represented by Tier 1 in the table above. This is attained when a behavioral program has high social and habilitative validity; that is, when the consumer is satisfied with the goals, procedures, and outcomes, and when those targets result in more benefits and less costs to the individual in the short and long term. The practitioner may use this table as an objective way to evaluate habilitative validity of a goal or procedure in cases when cultural conflicts increase the probability of making a subjective, or culturally biased decision about treatment. Although goals leading to outcomes classified in Tier 2 and 3 may be acceptable under some circumstances, evaluating habilitation should involve an ongoing reassessment of goals with clients and stakeholders, aimed at meeting Tier 1 criteria.

Culture-Centered Habilitative and Social Validity

In addition to using a set of objective criteria to define what constitutes an improved life for the client, it is also important to determine how the behavior change program will affect the social environment of the individual. Referring to the social significance of the goals, Wolf (1978) invites practitioners to consider if the goals of behavior change are “what society wants” (p. 207). Likewise, Hawkins (1991) defined habilitation as “the degree to which the individual behavioral repertoire maximizes the overall benefits and minimizes the overall costs to the individual and to others, including family, peers, and society” (p. 206). Thus, in addition to seeking the benefit of the individual, practitioners should also consider the extent to which a behavior change outcome improves the lives of members of the groups to which the individual belongs. Although the responsibility of the practitioner is to prioritize the best interest of the direct recipient of services (Behavior Analyst Certification Board, 2020), the values and preferences of the larger society need to be taken into consideration. After all, it is the members of the verbal communities to which the client belongs who arrange and deliver the social contingencies to which the client is exposed.

In situations of conflicting cultural values, the behavior change intervention may affect the individual positively but increase aversive conditions for the person’s immediate or more extensive social environment. This may make it difficult to make decisions about providing treatment when the cultural values of individuals and their cultures do not align. In these circumstances, practitioners will need to analyze which direction of change is likely to result in higher probabilities of access to short- and long-term reinforcers for individuals and also for the groups to which they belong.

When a person wants to change their behavior to be gender-conforming due to strong religious values, or when a family requests to use corporal punishment to decrease challenging behavior, what is in the best interest of the individual may not be in the best interest of his culture. A culture-centered analysis of habilitative validity may help categorize interventions into four quadrants (see Table 2) based on their outcomes on the larger culture and on the individual. In Table 2, Quadrant A represents a positive outcome for the individual and for society (Pos/Pos); Quadrant B represents an negative outcome for the individual and a positive outcome for society (Neg/Pos); Quadrant C represents a positive outcome for the individual but a negative outcome for society (Neg/Pos), and Quadrant D represents a positive outcome for the individual and for society (Neg/Neg).

Table 2.

Distribution of possible intervention outcomes for the individual and society

		Outcomes for the individual
		Positive	Negative
Outcomes for other members of the culture	Positive	A	B
	Negative	C	D

As shown in Table 2, Quadrants A (Pos/Pos) and D (Neg/Neg) indicate circumstances in which a behavior change program has a positive or negative effect on the individual and the cultures to which they belong. These cases present no conflicts. Despite the cultural views of the practitioner, if the intervention is likely to benefit the individual and his cultural groups, then the intervention should be implemented, and if it benefits neither, it should not. Quadrants B (Neg/Pos) and C (Pos/Neg), on the other hand, represent situations that require further analysis: the intervention may either benefit society but not the individual, or it may benefit the individual and have a negative impact on society. It should be noted that a “positive” outcome simply means there is some benefit, regardless of quantity or whether it is short- or long-term. Thus, Tiers 1, 2, or 3 represent at least some positive outcomes, whereas Tier 4 represents none.

In Quadrant B (Neg/Pos), the intervention may produce an overall gain for a community but an overall loss for the individual. An example of this might be a family requesting to change the homosexual behaviors of their teen child to avoid social punishment from their religious community. Although some members of the social environment of the child may be satisfied with the outcome, overall aversive conditions for the client will be increased, as their preferences are discounted, and access to their reinforcers diminished. Thus, even though the outcome may benefit others in the social environment of the client, this outcome should be considered unacceptable because it does not maximize gains for the client.

Quadrant C (Pos/Neg) is the clearest example of a conflict that requires consideration by the practitioner. In Quadrant C, the intervention results in an overall improvement for the individual but at some expense to a cultural group. An example of this might be a gay client who resides in a highly anti-homosexual community and requests to increase their social skills to engage socially with other homosexuals. Because this behavior change would not be in alignment with the cultural values of the community, the community may be affected negatively. The client, however, may experience a more fulfilling life by being able to engage in behaviors that increase reinforcement availability. If socializing with other gay individuals is more valuable for the client than social reinforcement from other sources, the intervention would result in an improved in life for the client. Although this could be considered an acceptable outcome, practitioners should seek to maximize overall gains for the client and his community in the long and short term. This may require making additional efforts to increase the acceptability and potential gains for the community, therefore pushing the intervention into Quadrant A (Pos/Pos). With the client’s consent, this might be accomplished by designing training programs targeting the communities’ beliefs about homosexuality and the thoughts and actions that may stand in the way of acceptance and inclusion of community members. In sum, although the benefit of the direct recipient of services should be prioritized, behavioral interventions should not result in aversive circumstances for families, communities, or other groups to the greatest extent possible. When aversive outcomes for families and communities are unavoidable, efforts should be exerted to minimize these outcomes while maintaining benefits to the client.

It is important to note that classifying intervention outcomes according to the Quadrants shown in Table 2 requires evaluating those outcomes in terms of their long- and short-term habilitative validity (Table 1). Hence, classifications of outcomes as positive or negative should not be reflective of what the practitioner considers moral, appropriate, or desirable for the client. Instead, these determinations should be the result of evaluating with the client how much those outcomes are likely to increase long- and short-term access to reinforcers and decrease contact with punishers. In this classification of habilitative value, Tiers 1 and 2 correspond to a positive outcome, Tier 3 corresponds to a temporarily acceptable outcome that may need further evaluation, and Tier 4 corresponds to a negative outcome (see Table 1).

Equally, the determination of habilitative value requires that practitioners consider how interventions affect the cultures to which the individual belongs, to then identify possible conflicts of values. Given that it is the members of a group who arrange and deliver reinforcers and punishers, considering cultural values is necessary for a contextual and accurate assessment of habilitative value. Thus, Tables 1 and 2, presented separately for analytical purposes, should be understood as mutually inclusive processes of evaluation that consider the values and cultural practices of clients and stakeholders. The appropriateness of an intervention can thus be assessed by identifying its habilitative value for the individual and the culture. A decision-making model representing this evaluation process is represented in Fig. 1. As the model shows, the main task of the practitioner is to evaluate predicted treatment outcomes with clients and stakeholders. Throughout this process, practitioners make adjustments to design an intervention likely to produce long-term benefits for the individual and the members of their culture (Tier 1, Quadrant A).

Fig. 1.

Decision model involving tiers of habilitation and conflicts of values between the individual and his social environment. Note. ST S^p = Short-term punishment. LT S^p = Long-term punishment. Pos/Pos = positive outcome for client/positive outcome for cultural community. Pos/Neg = positive outcome for client/negative outcome for cultural community

A Decision Model

The decision-making process begins with the identification of the goals of the behavior change program. The likely outcomes of these goals should be analyzed in terms of their habilitative validity and in conjunction with clients and stakeholders. If the client-centered habilitative assessment suggests that anticipated outcomes fall in the range of Tiers 2–3, practitioners should revise the goals to move the anticipated outcomes as close to Tier 1 as possible. A process of revision and reassessment of habilitation is repeated until either Tier 1 is reached, or the outcomes are acceptably close to Tier 1. Tier 4 outcomes (a decrease in both short- and long-term reinforcement) are unacceptable and therefore, corresponding goals or interventions should not be considered. On the other hand, Tier 1, 2, and 3 outcomes predict benefits for the individual that could vary in immediacy and magnitude; with Tier 1 resulting in ideal long- and short-term maximization of gains.

Following a client-centered habilitative assessment, the practitioner would then assess conflicts of values by considering the overall outcomes to society via a culturally informed society-centered habilitative assessment. Table 2 may be used to identify how others may be affected by the intervention and to orient the goal-adjustment process. At this stage, Quadrant D (Neg/Neg) and Quadrant B (Neg/Pos) have been ruled out because both involve an overall negative outcome for the individual (Tier 4). Thus, the only potential outcomes to identify are Quadrant A (positive outcomes for both client and society) and Quadrant C (positive outcomes for the client but negative outcomes for society). If Quadrant C (Pos/Neg) is identified, the practitioner should revise the goals to move closer to Quadrant A (Pos/Pos). If individual outcomes fall under Tier 2 or 3, client-centered habilitation should be reassessed to determine if the goals remain sufficiently close to Tier 1 for the client. Once goals that do not favor habilitation have been discarded and potential cultural conflicts (including the practitioner’s biases) have been minimized, practitioners should be ready to design and implement a culturally aware intervention. Throughout the process, practitioners should incorporate clients and stakeholders to determine the necessary goal adjustments to produce long-term benefits for the individual and the members of their culture. Note that because goals are based on cultural values and these define what is considered desirable and therefore determine the direction of change, we are focusing primarily on goals and expected outcomes, although the cultural relevance of procedures should also be incorporated into the assessment process.

Lastly, when using the model, it is important to remember that models are merely tools that represent processes in simplified ways (Kotsiantis, 2013). Much like a map, a model identifies only the main factors that may be present in a situation, and thereby does not attempt to be inclusive of all the variables at play. For example, among other things, it does not consider the unique nuances of the relationship between practitioner and client, their decision-making skills, their levels of involvement in the behavior change plan, or their ability to work collaboratively and adjust goals when needed. What a model does provide is a visual representation of factors to be considered at every step of the goal determination process, including boundary conditions, and possible directions based on an assessment of outcomes (Suarez et al., 2022).

Application Example: The Goal of Changing Stereotypic Behavior

Although stereotypy is exhibited to some degree by all individuals, autistic individuals often engage in these behaviors to a substantially greater degree (MacDonald et al., 2007). Often, the intensity or frequency of these behaviors is such that social stigma, exclusion from peer groups, (Conroy et al., 2005; Koegle & Covert, 1972; Loftin et al., 2008), reduced opportunities to learn, and familial stress (Harrop et al., 2016) are experienced as a result. For this reason, the effectiveness of behavior-analytic interventions to address these barriers has been extensively documented through years of research (Campbell et al., 2021; Lanovaz & Sladeczek, 2012; Rapp & Vollmer, 2005; Wang et al., 2020; Wei et al., 2021).

The social acceptability of reducing stereotypy, however, has been more recently questioned by neurodiversity activists and autistic individuals (see Graber & Graber, 2023). Because these behaviors may help autistic individuals cope with highly stressful situations or respond to intense stimulation, interventions aimed at decreasing stereotypical behaviors without the learner’s assent have been described as aversive, traumatic, and associated with a decreased quality of life (Leaf et al., 2022). For this reason, requests by caregivers to eliminate or decrease self-stimulatory behavior should be evaluated in terms of whether the expected behavior change will benefit the client, the family, and the larger culture. This is especially the case if what is perceived as a desirable outcome by the client, the family, and other community members, differs. The decision-making model described above could guide determinations about the appropriateness of services based on the social acceptability and the habilitative validity of the goals.

The first step would be to conduct a culturally informed habilitative evaluation of the proposed goal by identifying how the resulting behavior changes would alter overall levels of reinforcement and punishment in the short- and long-term. For example, decreasing stereotypy by exclusively withdrawing or preventing access to the reinforces it produces, will inevitably result in a short-term reduction in individual gains. If it is the case that stereotypy is a way of reacting to stressful situations or intense sensory stimulation, the client may also experience an increase in overall exposure to aversive events with no other coping alternatives. Because this would be considered a Tier 4 outcome, the goal should be reconsidered or not accepted. However, goals may be expanded to shift into more acceptable tiers of habilitation. For example, the practitioner could suggest decreasing the frequency or magnitude of stereotypy only during periods when it interferes with academic instruction, or in particular settings. In addition, to prevent overall loss in reinforcement density or possible contrast effects, the practitioner might suggest teaching the client alternatives to tolerate difficult situations in the settings where stereotypy is reduced. These options may offset the short-term decrease in reinforcement produced directly by stereotypy and increase access to new reinforcing contingencies due to the expansion of behavioral repertoires.

After considering the short- and long-term impact of intervening to eliminate stereotypy per request of the family, the practitioner may suggest bringing the behavior under discriminative control and shaping additional repertoires that may either match the function of stereotypy or provide competing reinforcers. It may be explained to the family how this alternative intervention not only minimizes the downsides of eliminating stereotypy but may also increase the opportunities to access other sources of reinforcement.

Upon identifying approximate Tier 1 outcomes for the client, the practitioner would also consider the potential outcomes of the proposed goal on the other relevant societal groups (e.g., family, school, and other communities). For example, the family may want to eliminate stereotypy for fear of social stigma and exclusion from social groups. To align the goals with Quadrant A (Pos/Pos) the family’s discomfort should be acknowledged and addressed. Thus, if the practitioner identified a Tier 1 or 2 outcome for the client, but both short- and long-term discomfort for the family (Quadrant C- Pos/Neg), the goals should continue to be adjusted while maintaining Tier 1 outcomes for the client. For example, if stereotypy involved high-pitched/high-magnitude vocalizations, additional options for discrimination training in specific community environments could target only the magnitude of vocalizations (see Campbell et al., 2021).

In addition, working with families or communities on value identification may contribute to resolve value conflicts. Through this process, the family may recognize that they value being accepting and supportive parents and that fear of rejection by other community members may impede value-oriented actions. Thus, the behavior analyst may work with the family to decrease control by stimuli evoking avoidant behavior and to augment the value of reinforcers related to value-oriented behaviors.

Understanding the contingencies influencing the behavior of the client in current and projected future contexts involves considering both culturally maintained contingencies (e.g., how does the family and greater society respond to these behaviors given their cultural values) as well as individual contingencies (e.g., functional relations that do not reflect the specific practices of a culture). Goal selection that is guided by culturally informed habilitative assessments at both the client and societal levels may contribute not only to resolve potential conflicts but also to minimize potential biases about which outcomes result in an improved quality of life for the individual and his immediate environment.

Summary and Conclusion

The notion of social validity reminds practitioners to target behavior changes that are socially significant to the individual and to society at large (Forehand & Kotchick, 2016; Wolf, 1978; Van Houten et al., 1988). One way to adhere to this standard is by adopting a culturally aware approach towards intervention planning. In this approach, practitioners identify clients’ values and preferences that are culturally shaped and maintained. In particular, the culturally aware behavior analyst approaches data collection, reinforcer selection, assessment procedures, and treatment programming in light of an understanding of the cultures with which the client identifies (Fong et al., 2016; Fong & Tanaka, 2013). However, although the importance of adhering to this general standard is widely accepted, occasionally cultural values between the client and larger society may conflict to an extent that the best course of clinical action is uncertain. In these situations, practitioners may find it difficult to decide between acting according to clients' stated values and goals and those of their immediate cultures.

What society considers good is largely verbally constructed and therefore subject to change with the continued evolution and selection of cultural practices over time. Although intervening based on the requests and stated needs of the client addresses social validity, habilitative validity should not be neglected as it is also a defining factor in determining the client's best interest (Hawkins, 1984, 1991). Because clients and stakeholders may approve/disapprove of a behavior change program based on its immediate gains/costs, behavior analysts may guide the process by pointing out long-term treatment effects for the client and their social environments. Desirable outcomes in the near future may have negative long-term consequences that may be discounted by clients and stakeholders. Likewise, what may be thought of as an immediate aversive outcome for a community may have positive, long-lasting effects for all members. Such habilitation assessments should be both client- and culture-based, because cultures often serve as reinforcing and punishing contexts for an individual’s behavior.

To guide decisions about treatment in situations that may involve conflicts of cultural values, we suggest a decision-making model (Fig. 1) that evaluates the habilitative validity of treatment outcomes during the goal-determination process. This evaluation, conducted with clients and stakeholders, may also minimize the influence of the practitioner’s cultural biases when determining which outcomes may be most beneficial to the client when values differ. As contingencies of reinforcement and punishment are largely arranged by the members of the cultures of which the client is a member, an analysis of outcomes in terms of habilitation cannot be done without regard of the impact of the intervention on the social contexts of the client. Further, because describing events as good or bad, or positive or negative, is highly relative to other relations and to events that are part of larger contexts (Perone, 2003), examining the long- and short-term outcomes of an intervention in terms of habilitation may also help minimize the practitioner’s cultural biases when determining a course of action.

Cultural values may conflict when a positive outcome for an individual causes harm to the members of their culture, or when a goal that is aligned with the values of a culture produces aversive outcomes for the individual. Table 2 illustrates the possible outcomes of behavior analytic interventions categorized into four Quadrants: Quadrant A, the intervention benefits the individual and their cultures; Quadrant B, the intervention has a negative impact on the individual but benefits the client’s social environment; Quadrant C, the intervention benefits the individual but has a negative effect on their social environments, and Quadrant D, the intervention has a negative effect on the individual and their social environments.

If the behavior change program requested by a client or their family benefits the individual and does not cause harm to society, the behavior analyst should provide services even if doing so conflicts with their cultural values and provided that the conflict is not so significant that it impedes effective treatment. In a situation of conflict, the likely benefits of the intervention for the consumer and society supersede considerations based on personal cultural beliefs or values.

Even though the significance of cultural awareness for behavior analytic practice is widely recognized, a framework for intervention planning when conflicts of values become evident is still needed. The decision model presented here suggests a systematic evaluation process that incorporates individual, and culture-based habilitative and social validity, in the goal determination process. Although empirical support for decision making models in behavior analysis is still needed, the effectiveness of decision-making models is well-established in other fields.

Decision-making models are used regularly in health-related disciplines (e.g., nursing, medicine, psychology, and public health) to guide practitioners through the assessment and treatment processes, or as a problem-solving tool for making informed clinical decisions in case conceptualization or diagnostic assessment (Banning, 2008; Christon et al., 2015; Kotsiantis, 2013; Suarez et al., 2022). Furthermore, empirical evidence has shown that practitioners who use these models provide higher quality of care, make accurate diagnoses, and are successful at selecting appropriate health-related preventative strategies (Banning, 2008). Given their practicality for guiding effective action, behavior analysts have also suggested their use in a variety of areas that require structured decision making including providing services in crisis situations through telehealth (Colombo et al., 2020), navigating ethical dilemmas (see Suarez et al., 2022, for a review), choosing appropriate behavior measures (Le Blanc et al., 2015) or interacting with stakeholders or other professionals about nonbehavioral treatments (Shreck & Miller, 2010; Brodhead, 2015).

Because of their increasing popularity in applied behavior analysis, however, some considerations are worth noting. First, practitioners should remember that a model does not replace proper training, experience, supervision, and data informed clinical judgement. It is merely a guide toward orderly and systematic determination of a course of action. Using the model suggested here requires competency estimating probabilities of outcomes at each step, and the ability to establish a relationship with clients and stakeholders that facilitates accurate evaluation. Second, empirical evidence showing that this model can be used as a strategy for making culturally informed decisions when cultural awareness reveals conflicting cultural values is needed. As it is typically done in medical and nursing research, comparing social validity measures from practitioners using the model, to measures from practitioners not using the model may provide initial effectiveness indicators.

Lastly, it is important to note that as simplified depictions of processes, decision-making models represent circumstances in terms of binary categories and thus, fail to capture the complexities, idiosyncrasies, and elements of uncertainty inherent not only in clinical work, but also in cultural valuing. The model suggested here evaluates habilitative validity by assessing the extent to which reinforcers or punishers for the individual and their cultures may be likely outcomes of behavioral intervention. However, the categories suggested in Tables 1 and 2 may not be mutually exclusive, and reinforcers and punishers may be different in number, or have different magnitudes. Perhaps a more accurate assessment could result from incorporating weighted values within the quadrants of Table 2. This could be done by quantifying the magnitude of positive or negative impacts of the intervention on the individual and society. Future research could evaluate the effectiveness of this model and examine its perceived utility and practicality. Building a reliable base of empirical support for decision-making models in behavior analysis will validate their use as a tool to support culturally informed behavioral care.

When cultural values conflict, choosing whose values are right or better is necessarily subjective and impractical, as there is no absolute or scientific standard of what is good. Unless habilitative outcomes are assessed with clients and stakeholders, practitioners may identify the outcomes that result in the best interest of the client based on their own cultural values. On the other hand, practitioners should also be cautious not to rely solely on consumer’s satisfaction when making treatment decisions, because the client's stated preference may not always correspond with maximized habilitation (Hanley et al., 2005). Responsiveness to cultural values should be considered in the context of a thoughtful risk/benefit analysis of the goals, procedures, and outcomes of the requested behavioral services.

In sum, refining goals based on habilitation outcomes (as shown in Fig. 1) prevents practitioners from reacting to conflicts in terms of personal biases and judgments, from incorporating social validity in the absence of habilitative validity at the levels of the individual and the culture, and guides practitioners to make decisions about services when conflicts of values are involved. Being responsive to cultural values does not unequivocally mean honoring all requests from clients and stakeholders. Because most human behavior is culturally learned (including the behavior of the behavior analyst), the limits of cultural responsiveness need to be explicitly situated within the context of the general goal of ABA: to produce behavior changes that will benefit the individual and society. To accomplish this goal, behavior analysts work to arrange environments that allow them to be successful in their communities. Because most of these environmental events are also cultural events, the work of the behavior analyst necessarily involves consideration of cultural values and evaluation of conflicts. This can be accomplished by using a framework for resolution that is culturally aware, socially valid, objective, and that results in the greatest benefit for the individual in their social environments.

Recognizing conflicts and biases through cultural awareness is only the first step in developing behavior change programs that are responsive to the different cultural environments to which a client belongs. As proposed here, assessing the habilitative validity of interventions is consistent with a cultural humility approach that emphasizes learning about the client and determining which outcomes are likely to result in an improved life for the individual and their cultures. Moreover, because as products of cultural evolution, cultural values and practices are not uniform or static, the assessment process calls for a generous dose of what Foxx (1996) called behavioral artistry, i.e., the behavior of the analyst should be equally flexible, creative, and adaptive. Programming for culturally relevant and socially valid behavioral intervention requires developing a relationship with clients that involves respecting rather than imposing, assessing rather than assuming, and when conflicts arise, adjusting goals and procedures to produce lasting changes that will benefit the client in their social environments.

Data availability

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Declaration

Conflict of Interest

The authors declare that they have no relevant financial or non-financial interests to disclose.