Ensuring that All that Glistens is Gold: ACTing with Integrity

Abstract

Tarbox, Szabo, and Aclan (Behavior Analysis in Practice, 1-22, 2020) provide a compelling rationale for the inclusion of Acceptance and Commitment Training (ACTraining) within the scope of behavior analytic practice to address experiential avoidance in clients and parents. We agree with the main tenets of the authors’ argument, and suggest that ACTraining may be particularly beneficial if applied with frontline staff in behavior analytic service settings. We provide a brief overview on the precedent for ACT in the workplace, but conclude by underscoring the need for considerable curricular development in graduate training programs so that behavior analysts can implement ACT with integrity.

Scientists are often reluctant to adopt paradigm shifts, and behavior analysts are no different. As Kuhn (1970) advises, some may fervently cling to a worldview because paradigm shifts signal that the field in which one trained and matured is changing. In a discipline with firm and sometimes dogmatic philosophical commitments such as ours, it is understandable that shifts in paradigm might be unsettling. Nonetheless, Kuhn (1970) asserts that a scientific community must have a clear vision of paradigms or worldviews so that its philosophical, theoretical, and methodological foundations can guide the research of all who practice within that community. A failure to shift paradigms can hinder progress, an unsettling outcome for a science focused upon improving the human condition. Some of these concerns loom over the incorporation of Acceptance and Commitment Training (ACT, or ACTing) into the practice of behavior analysis. A similar reluctance marked the trajectory of Relational Frame Theory (RFT), which provides the theoretical underpinnings for ACT as an empirically verified expansion of Skinner’s (1957) analysis of verbal behavior – a hesitation that became more and more unfounded as the volume of data in support of RFT grew.

The troubling part for many seems to be that the problematic patterns of language targeted in ACT interventions, including rigid rule-following and perceptual responses to relational networks, often occur covertly, where observation and measurement are difficult (see Baum, 2002). Whether or not to concern ourselves with private events is an exceptionally long-standing dispute in the field, long preceding both ACT and RFT. Some behavior analysts seem to forget or are unaware that Skinner himself not only granted permission for the inclusion of private events in the analysis of behavior, but insisted that any thoroughgoing science of behavior must include that which occurs covertly. Many scholars of behavior analysis have justified the incorporation of private events into research and practice, and proposed strategies for study: Anderson et al. (2000) offer that private events may occupy the status of both independent and dependent variables – and should in fact be treated as such, and Palmer (2011) suggests that one way of studying covert verbal behavior may be to observe and measure reliable overt indicators, such as observing instances of trembling as indicators of anxiety. Hence, the argument over whether covert behavior warrants study in the analysis of behavior is by now a highly antiquated debate (see Friman et al., 1998). In addition, consistent with the contextual behavior science stance is the notion that in a behavioral analysis, context is the unit of behavioral selection, where context includes learning history, genetics, the current situation, the entire range of consequences, and private events (Dougher & Hamilton, 2018). Given Bailey and Burch’s (2016) acknowledgment that behavior analytic practitioners ought to regard the entire context as their client, it would seem that the time for Applied Behavior Analysis to cast aside its worries about paradigm shifts is long overdue.

Tarbox et al. (2020) provide a compelling rationale for the adoption of ACTraining as a “behavior analytic approach to addressing problematic verbal behavior involved in behavioral rigidity and insensitivity to socially significant contingencies,” (p. 1). With an eye toward Kuhn’s (1970) instruction, Tarbox et al. (2020) importantly suggest that the inclusion of ACTraining within the parameters of Applied Behavior Analysis may not be that huge a paradigm shift at all; in fact, the authors reason, ACTraining fits logically into the very same basic natural science framework. To wit, all of the ACT components can be conceptualized in behavior analytic terms, oft-described as middle-level terms or “repertoires” to be targeted for instruction. Values are conceptualized as verbal motivating operations (p. 4); present moment awareness can be regarded as the tacting of one’s attention (p.5); acceptance is defined as a skill to replace avoidance of unpleasant covert stimulation; defusion is a repertoire intended to “disrupt the function” of unworkable rules (p. 6); self-as-context may be viewed as a “flexible perspective-taking repertoire” (p. 7); and committed action is defined as a “response class of socially significant overt behaviors that move one in the direction of one’s stated values” (p. 8). The end result of intervening in all six components is the strengthening of generalized operant repertoires that are transportable to all facets of a person’s life (Tarbox et al., 2020). ACTraining, as potentially practiced within ABA, is thus argued by the authors to meet the same standards that define any other behavior analytic practice (Tarbox et al., 2020, p. 4).

In this commentary, we express enthusiastic support for the position articulated by Tarbox et al. (2020). We extend their justification to the gap that ACTraining may fill in meeting the needs of frontline workers in behavior analytic service settings – the very people who are expected to implement interventions with high fidelity under what are often stressful and uncomfortable conditions. We provide a brief overview on the precedent for ACTraining in the work-place, including research documenting its efficacy and relevance in promoting quality job performance and well-being among human service delivery staff. In so doing, we underscore the importance of helping service providers to live lives characterized by “fullness and vitality” (Wilson & Dufrene, 2009) for their own well-being and for that of the clients whom they serve. As a caveat, we conclude by encouraging the behavior analytic community to examine how we are currently fostering skill development in ACTtraining in graduate training programs, including what curricular adjustments must be made to ensure that the implementation of ACT occurs with integrity.

Experiential Avoidance in Frontline Staff

Tarbox et al. (2020) focus much of their justification for the adoption of ACT by behavior analysts for those working with parents, particularly parents who may be struggling to implement behavioral procedures with fidelity and experiencing discomfort at doing so. The authors describe parallel applications for practitioners less frequently throughout the paper. We certainly agree that parent training and support is an important area of practice where ACT may not only be beneficial but warranted. We suggest that ACTraining with frontline staff is another area ripe for investigation, particularly given the behavior analyst’s responsibility to supervise and support such staff, be they Registered Behavior Technicians or other paraprofessionals. As a field, applied behavior analysis has been slow to recognize that the well-being of those implementing behavior plans matters, least of all because clients’ well-being is affected by their interactions with staff and other caregivers. Research has shown that in fact working in behavior analytic service settings, much like other human services, is highly likely to engender psychological discomfort for a myriad of reasons, including but not limited to the following: First, the work may at times be tedious and frustrating. Second, a client’s progress may be slow, leading a clinician to question their skill level and competency. Third, collaborating with parents and other professionals may be challenging for new clinicians. Last, managing severe challenging behaviors may be frightening or anxiety-provoking for even highly skilled clinicians, particularly while working in community settings. Perhaps not surprisingly, Hatton et al. (1999) reported that one-third or more of frontline staff working in human service settings report stress levels indicative of a mental health problem. Similar results have been reported for board-certified behavior analysts. Plantiveau, Dounavi, and Virues-Ortega (2018) surveyed a diverse incidental sample of early career behavior analysts and found that approximately two of three respondents reported experiencing moderate to high levels of job burnout and stress, whereas one in three reported experiencing little to no satisfaction in their job. In keeping with the notion that the context is our client (Bailey & Burch, 2016), analyzing the basis for these worrisome findings from the perspective of behavioral inflexibility and experiential avoidance seems in order.

Little et al. (2020) provide the analysis that likely explains the experiences of many practitioners who initially enter into the profession because they value helping or caring for others. For the reasons mentioned previously, the likelihood of psychological discomfort is high in many human service settings, and stressful situations may engender covert self-rules surrounding the avoidance of the unpleasant psychological experience itself. For example, “make sure you don’t do this so that there isn’t an incident,” “I’m just going to go through the motions,” and “you just have to get through the day,” may be just the sorts of self-rules that a once-motivated staff member may follow in hopes of avoiding psychological discomfort – at the expense of losing contact with the very contingencies that at one time sustained their interest in the job (see Bethay et al., 2009). The result may well be a staff member who has forgotten what it was that they once valued about their work because they are far more engaged in avoiding aversive stimulation. Their repertoire at work may become narrow, restricted, and lacking in creativity and vitality. In short, the clinician may sacrifice the pursuit of long-term positive reinforcement for shorter-term escape or avoidance. Such staff may well benefit from ACTraining with a specific emphasis on values interventions, in which rule-following repertoires are established that support behavior oriented towards longer-term reinforcers that the work-place may in fact supply (Tarbox et al., 2020).

Not surprisingly, a precedent exists for the implementation of ACT in organizational settings to enhance behavioral flexibility among employees. Noone and Hastings (2010) evaluated the utility of a protocol known as the Promotion of Acceptance in Carers and Teachers (PACT) on the perceived stress levels in support staff working with individuals with disabilities. ACT was implemented in the format of a 1- to 2-day training workshop divided into morning and afternoon sessions. The morning session of Day 1 focused upon the demands and challenges of caring, and the afternoon session encouraged participants to identify their values in relation to their job. “Coat of arms about my values” is an example of a values exercise that was implemented on Day 1 (Noone & Hastings, 2009, p. 51). The metaphor proceeds as follows:

Throughout history, symbols on a coat of arms represented what a family stood for and important actions that the family members had accomplished. The coat of arms was displayed with honor. In a way, this agency is like a family, a team. How might your coat of arms look like and stand for in your role at the agency? (Staff are provided a blank coat of arms and asked to express their values on the worksheet. Values are shared amongst the group and actions based on that value are explored and assigned.)

The second day consisted of review and the introduction of additional metaphors from Hayes et al. (1999) including “bubble in the road” (p. 230), which proceeds as follows:

Imagine that you are a soap bubble. Have you ever seen how a big soap bubble can touch smaller ones and the little ones are simply absorbed into the bigger one? Well, imagine that you are a soap bubble like that and you are moving along a path you have chosen. Suddenly, another bubble appears in front of you and says, “Stop!” You float there for a few moments. When you move to get around, over, or under that bubble, it moves just as quickly to block your path. Now you have only two choices. You can stop moving in your valued direction, or you can touch the other soap bubble and continue on with it inside you. This second move is what we mean by “willingness.” Your barriers are largely feelings, thoughts, memories, and the like. They are really inside you, but they seem to be outside.

The session ended with each participant writing a personal statement of commitment concerning their job. Although self-reported stress levels were not shown to decrease following the workshops, psychological discomfort did, suggesting that while the stress of the workplace did not change, how the staff perceived and responded to their experience of stress during their work-day did in fact change following the PACT intervention.

Similar results were reported by Brinkborg et al. (2011), who conducted four 3-hour ACT workshops with Swedish social workers. The workshops were adapted from the ACT-Stress Management Intervention (SMI) protocol (Bond, 2004; Bond & Hayes, 2002), which includes a variety of metaphors and experiential exercises for identifying and clarifying values while encountering obstacles in the workplace. Following ACT workshops, the participants reported decreased levels of burnout and stress when compared to a wait-list control group, also measured via standardized questionnaires. Likewise, Dahl et al. (2004) implemented ACT with public health workers with significant numbers of sick days at their places of work. These participants were exposed to four 1-hour individual sessions that focused on work-related values. Compared to a medical treatment-as-usual group, which included free access to medical care such as a physician, physical therapy, and/or a specialist, participants in the ACT group decreased their use of sick leave over the course of 6 months following the ACT interventions. Together, findings from these studies show promise for ACTraining in promoting behavioral flexibility in a variety of practitioner-oriented professions, thus reinforcing Tarbox et al.’s (2020) assertion about its increasing popularity in a variety of health and human service professions. Importantly, it appears that the ACT trainings can be relatively brief in order to be effective (see Flaxman et al., 2013).

While promising for our aims, many of the published studies on ACT in the work-place have been conducted using standardized questionnaires as dependent measures. To further solidify the placement of ACT within the domain of Applied Behavior Analysis, it will be necessary to replicate such studies using single-subject methodology with objective, valid, and reliable measures of behavior change, both of which are defining characteristics of research in our discipline. This way, a functional relationship between ACT and behavior change can be clearly ascertained. Several such investigations have shown that ACT interventions can increase the degree to which frontline staff engage with their clients. Castro et al. (2016) found that workshops on values and committed actions produced a substantial increase in the frequency with which staff in day treatment programs for adults with developmental disabilities interacted with their clients – a clinically significant finding as baseline frequencies of engagement were near zero levels. Staff also reported that they enjoyed the opportunity to connect with their co-workers and supervisors in this manner and found the discussion of values helpful for their work at the agency. Chancey et al. (2019) reported similar findings following frontline staff’s participation in several brief mindfulness exercises before the start of their work-day.

A Word of Caution

Tarbox et al. (2020) conclude by acknowledging that the future looks bright for ACTraining in behavior analytic practice. The authors have provided a compelling argument and prompted a valid conversation for the field. While the future may indeed look bright, all that glistens may not be gold: There are no specialized credentials associated with ACTraining, nor are there competencies to ensure the fidelity of its implementation. Furthermore, as Tarbox et al. (2020) delineated, there is much to be learned. Practitioners must determine whether ACTraining is warranted following functional assessments (see Sandoz et al., 2021). They must be proficient at recognizing problematic patterns of rule-following, and be able to discern how to best implement ACT alongside other behavioral interventions. They need to be competent at evaluating the efficacy of ACTraining and change course when treatment progress and client acceptability of the treatment dictates. They must identify when an individual is in crisis so that they can make a referral to the appropriate professional rather than attempting to address the situation themselves. For those hoping to pursue training in ACT, in-person workshops and online webinars are not difficult to find, but rarely do such trainings specify mastery criteria for attendees to attain before competency can be confirmed. In addition, few graduate training programs in behavior analysis include content specific to ACT and other topics that would seem to be essential for quality implementation. This includes, for example, relationship-building, clinical interviewing, and rapport building. Thus, while Tarbox et al. (2020) have provided the justification, we now need the framework for teaching ACT skills to practitioners and ensuring that it is implemented and evaluated with integrity, just as we do with all other behavioral interventions.

Others in the behavior analytic community have advocated for training specific skill sets to practitioners that might be considered a precursor to practicing ACT. For example, Taylor et al. (2019) argued that “enhanced relationship skills” (p. 654) such as empathy and perspective-taking should be targeted as a component of educational curricula. These authors found that parents of children with autism rated behavior analysts low on “caring about the entire family, acknowledging mistakes or treatment failures, and being patient and reassuring” (Taylor et al., 2019, p. 658). Likewise, LeBlanc et al. (2020) found that out of 225 practicing behavior analysts surveyed, 72% indicated that they had no direct training on building therapeutic relationships during their graduate training, and 91% reported that these skills were fundamental throughout their workday! These findings do not bode well for a profession hoping to be successful with ACT.

Fortunately, a foundation is materializing for the use of behavior analytic instructional procedures to teach precurrent skills such as relationship-building and active listening to students and practitioners. Taylor et al. (2019) proposed an elaborate curriculum for teaching listening, empathy, and compassion to practitioners based upon behavioral skills training. This curriculum awaits empirical evaluation but shows promise for its inclusion in graduate-level practicum or professional development courses. Canon and Gould (2021) used a variation of behavioral skills training consisting of instructions, clicker training, and role playing to teach mindful reflecting, asking questions with curiosity, and appreciating to graduate-level practitioners. Although the participants acquired the skills with ease, generalization was limited. Continued development and validation of procedures such as these is critical if indeed ACT is to be incorporated with integrity into behavior analytic practice.

In closing, we agree with Tarbox et al. (2020) that ACTraining is well suited to fill gaps that require filling in behavior analytic practice, particularly where the well-being of front-line practitioners and their quality engagement with those they serve is concerned. But as explained in this commentary, we as a field have considerable work to do before this can be accomplished. As far as the future looking bright, we certainly hope so.

Declarations

None of the authors of this article have conflicts of interest to disclose. No human participants were involved in producing this article, so informed consent was not collected.