5 Things to Know Before Starting a Practice

5 Things to Know Before Starting a Practice

5 Things to Know Before Starting a Practice

Starting a practice in the mental health field can be tricky and intimidating, but there are some things you need to keep in mind to ensure that your business gets off to the right start. These five points are important to know before starting a mental health practice, so you can make sure your business has the best chance of succeeding from the beginning.

1) Get Educated
While it is important to have an idea of what you’re doing when starting your practice, there is also value in getting educated. You should learn about how insurance companies work, how to make money and most importantly, how to get clients. There are many different ways of approaching these tasks but be sure you are on track before you open your doors. You don’t want take your first client and realize that you aren’t ready! When starting a business or practicing any profession for that matter, knowledge is power. So as you embark on your new endeavor, know exactly what steps need to be taken and why they are necessary. If you understand why certain things need to happen at certain times during startup, then making decisions will become easier down the road.

2) Figure Out Your Mission
When starting your own practice, it’s crucial to figure out why you want to start it. Is it because you’re passionate about helping people? Do you have financial problems? Or do you just love meeting new people and talking about your interests for hours on end? Figure out what drives you so that in those moments of doubt, or just when things get rough (and they will), you can remind yourself of why you started practicing in the first place. You may also need to adjust your mission statement as time goes on, but getting started is an important step in itself. And don’t forget to share with others why you started practicing! Maybe they too would like to join you!

3) Set up your Website
Setting up your website is key for making sure you’re able to convey who you are and what you do to potential clients. Whether you’re setting up a full-blown site or simply having something created on WordPress, having an online presence is crucial for any mental health professional hoping to start their own practice. But if one thing that working with tech companies has taught me, it’s that simple websites often work best. If your website doesn’t look good, no one will want to hire you—no matter how great of a therapist you are. And while I think it’s important to have some semblance of design in place (to make sure people actually read what you write), overthinking things can be counterproductive. For example, I once spent hours agonizing over font choice before realizing that people don’t care about fonts—they care about helping themselves feel better. So, my advice: keep it simple. Make sure you include information about yourself and your services so that people know exactly what they’re getting when they come to see you. Beyond that, just let nature take its course! You might be surprised by how many new clients start coming through your door after just a few weeks or months.

4) Branding
If you’re serious about starting your own mental health practice, there are several things you need to do right out of the gate. Think branding and marketing. Consider what type of service offerings, location, facilities and patient care you want and be sure that they’re all tied together in one cohesive package. Most importantly, make sure that your brand is unique in some way from other providers in your area. Otherwise, why would anyone choose you over someone else? There are thousands of mental health professionals across America and many patients have no idea how to find them; having a strong, recognizable brand will help you stand out from the crowd. In addition, get started on social media channels as soon as possible; these sites are great for reaching potential clients and keeping up with their needs and concerns. Finally, put together a website to establish credibility with patients—and prospective patients—right away. Make it professional-looking without being too fancy or complicated (remember: most people looking for services aren’t web designers). When people visit your site, make sure they can easily access information about fees, insurance policies and payment options.

5) Marketing
As you start your practice, remember that you are your own best marketing tool. Other mental health professionals and potential clients will want to know why they should pick you over another therapist. Start by creating a website where people can learn about your practice, background, and beliefs. It should feature information about your specialty areas and any treatment approaches that are unique or different from other therapists in your area. Keep in mind that social media is also a powerful marketing tool for both finding and communicating with potential clients. The more active you are on Facebook, Twitter, LinkedIn, and Instagram (and others), the more opportunities there will be for people to learn about your practice.

Starting a Practice that includes Clinical Behavior Analysis
There are many aspects to simply starting a practice, all of these become somewhat more complicated if you are moving into Clinical Behavior Analysis – either as a behavior analyst or a dually licensed clinician. You need to strongly consider your scope, limitations, regulations in your area, the availability of on-team multi-disciplinary staff to support you, and/or external consultation and supervision. Each of the above areas of focus will also need to be considered from the perspective of starting this unique type of practice or launching a business with an integrated practice team. If you’d like to know more about these topics, visit our Clinical Behavior Analysis series in the “Shop” or reach out to us.

 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

What is ‘clinically relevant behavior’: Sign or sample

What is ‘clinically relevant behavior’: Sign or sample

As discussed by Ollendick et al. (2004), abnormal and clinically-relevant behavior can be viewed as either a “sample” or as a “sign.” To what extent does this difference, in turn, make a difference in the assumed temporal and situational consistency of such behavior?

Whether you view abnormal and clinically-relevant behavior as a “sample” or a “sign” makes a significant difference in whether you consider such behavior to be consistent over time and in various situations. If a behavior is seen as only a “sample” of a person’s behavior then there is no expectation that this behavior will be consistent over time or in different situations. When behavior is only said to be only a “sample” the implication is that you expect variation in the behavior. If the behavior is thought of as a “sign”, however, the implication is that the behavior is only an indication of an underlying trait or pathology which implies that the behavior should be more constant through time and situations. From this view as long as the underlying pathology, trait, etc. is present then behavioral “signs” of the underlying construct should also be present. In the relation to psychological problems this “sign” conceptualization, however, is most often a circular or reifying argument. A “sign” behavior indicates a “disorder” when a “disorder” only indicates a collection of symptoms. This conceptualization provides no particular “cause” for the behavior other than itself. This conceptualization is an artifact of using the methods of physicians to understand physical disease to understand human behavior.

The understanding of behavior as a “sample” vs a “sign” also impacts how problem behavior is conceptualized and in turn how assessment is conducted. If the behavior is only a “sample” of a person’s behavior at a certain time in a certain situation than an assessment of the person’s behavior in other situations is likely to be important. If the behavior is a “sign” then assessment over one time period in one situation is more acceptable because the behavior is assumed to be stable as long the “disorder” is constant. Assessment of “sample” behavior may also involve a less predetermined route than assessment of “sign” behavior. As behavior seen as a “sample” implies that there may be a wide variety of other problem behaviors that may exist with the target behavior. Thus, assessment may include any route of questioning, observing etc. that helps the clinician learn about all problem behavior and any possible relationships between the environment and problem behaviors. Because the behavior is expected to vary by situation, factors related to the situation may more likely be considered part of the conceptualization of the problem and should be assessed. If behavior is conceptualized as an “sign”, however, the behavior is related to internal factors and assessment is more likely to focus on assessing for other problem behaviors that are understood to cluster to indicate the underlying pathology. Assessment of environmental/situational factors is also less important if the behavior is understood to indicate pathology as the person’s behavior should continue to indicate the pathology across situations. In other words, assessment from a “sample” behavior perspective is more likely to be all-inclusive in assessing what other behaviors are present and what factors may be causing the problem behavior. Assessment from behavior as a “sign” perspective is more likely to be limiting in the sense that the clinician begins by looking specifically for behaviors that indicate a disorder and is more likely to ignore situational factors in the behavior and understand the “disorder” indicated the cause of the problem behavior.

 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

The ACT Practitioner’s Perspective on Adolescent Suicidality

The ACT Practitioner’s Perspective on Adolescent Suicidality

by Amy R. Murrell, Ph.D.

             The paper summarized here, was written by myself and former students (Al-Jabari, Moyer, Novamo, and Connally), and published in the International Journal of Behavioral Consultation and Therapy in 2014 examines the problem of adolescent suicide from an Acceptance and Commitment Therapy (ACT) practitioner’s perspective. At the time of the paper’s publication, according to the Centers for Disease Control and Prevention (2014), approximately 4,600 young people completed suicide annually in the United States. At the time of this summary, that number is nearly 7,000 (Centers for Disease Control and Prevention, 2019). I chose to summarize this paper for two reasons: I wish that number were moving in the opposite direction, and I think the conceptualization written about here is useful.

            Of course, more adolescents attempt suicide and have ideation about suicide than complete it. Those youth are important to discuss from a functional contextual point of view, and that is what this article does. It is divided into seven major sections. The first section discusses the prevalence, antecedents, and consequences of adolescent suicidal behavior. The second introduces experiential avoidance, and the third introduces the ACT model. The next section is “the heart” of the paper, giving an ACT conceptualization of adolescent suicidal behavior. The next two sections talk about a specific client, first hypothetically and then with a case example. The final section summarizes the state of relevant empirical evidence to date (at the time of publication). Here I will cover just a bit of each section, so you get a feel for the article’s content. I am biased, but I think you should give it a read.

            The article states that there are some behaviors (e.g., substance abuse) that co-occur with and may predict suicidal ideation and attempt, but there are also individuals who have no previous diagnosis who have suicidal behavior. It is obvious, therefore, that there is no set pattern or easy prediction – with one caveat. Past behavior is the best predictor of future behavior. The costs of suicidal behavior are great. According to Yang and Lester (2007), every year in the United States alone, non-fatal suicide attempts cost about 4.72 billion dollars. The consequences go far beyond money, though. The article talks of cluster suicides, survivor guilt, and worsening negative emotional experiences. 

            This leads into the discussion of experiential avoidance (EA), noting that attempts to control, suppress, lessen, or avoid those negative emotions (or thoughts, bodily sensations, and/or places that might make them more likely) may worsen distress. Next, ACT is introduced as a treatment to address EA. In both the section on EA and the section on ACT, assumptions of functional contextualism are addressed (e.g., all behaviors serve specific purposes in specific settings). This is the perfect segue to Chiles and Strosahl’s (2005) definition of suicidal behavior as learned behavior that functions as an avoidance of – or escape from – negative emotions.

            In brief, ACT views suicide as a perfectly reasonable solution to feeling stuck or hopeless. Suicidal behavior is seen as the result of normative human language and cognition processes. The article states that normalizing suicidal behavior shifts the therapeutic context to an open and honest one that may help reduce client shame. Just as a little teaser, there is a discussion about relational framing related to thoughts of suicide and how that may bring relief. There are several intervention strategies suggested (e.g., values with specific future-oriented goals). The hypothetical client is used as a way to provide context for how suicidal behavior, in general, might be discussed. The issues of safety planning and contracting are discussed in this section as well.

            The ACT approach to these issues is different from many other clinical takes; if you don’t know it, you might find it an interesting read. A de-identified client example illustrating how defusion, values and several other ACT components were used to address suicidal behavior is the last section before empirical evidence is provided. The case example illustrates that, as is often the case, the client remains quite anxious yet she is living out her values more and thinking of suicide less.

            The data summary indicated the need for research on suicidal behavior. This is still a particular need. Fortunately, however, in the last six years the evidence for ACT with adolescents has increased. Since this paper was written, there have been 10 randomized controlled trials with participants under the age of 18. For details, see the Association for Contextual Behavioral Sciences State of the Evidence Page.

References:

ACBS State of the Evidence Page https://contextualscience.org/state_of_the_act_evidence.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2011b). Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Last Updated February 25, 2014. [cited]. Retrieved from http://libproxy.library.unt.edu:2465/injury/wisqars/fatal_injury_reports.html

Centers for Disease Control and Prevention, NCHS Data Brief, No. 352, Oct 2019 [ online]. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

Chiles, J. A. & Strosahl, K. D. (2005). Clinical manual for assessment and treatment of suicidal patients. Arlington, VA, US: American Psychiatric Publishing, Inc.

Murrell, A. R., Al-Jabari, R., Moyer, D., Novamo, E., & Connally, M. L. (2014). An acceptance and commitment therapy approach to adolescent suicide. International Journal of Behavioral Consultation and Therapy9(3), 41–46. https://libproxy.library.unt.edu:2147/10.1037/h0101639

Yang, B., & Lester, D. (2007). Recalculating the economic cost of suicide. Death Studies31(4), 351–361. 10.1080/07481180601187209

 

Multi-trait Multi-method Assessment

Multi-trait Multi-method Assessment

 If you’re looking to move into Clinical Behavior Analysis, you need to have some understanding about how “psychology” talks about and tends to make judgments about the types of measurement they typically use. 

Measures in psychology generally are compared to each other to determine whether they have adequate “convergent”, “discriminant”, and “construct” validity. Convergent validity is determined by examining the correlation between measures that are expected to measure the same “thing” as the measure being evaluated. For example, if one is evaluating a measure of “generalized anxiety disorder” symptoms – you would expect the correlation between responses on this measure to correlate with the same sample’s responses on other measures of “generalized anxiety” symptoms. “Discriminant” validity is the degree to which the measure being evaluated correlates with measures with which we would not expect it to be highly correlated. For example, if one is developing a measure of “generalized anxiety” symptoms a very high correlation between your samples responses on this measure and say a measure of “psychosis” symptoms would suggest that your measure of generalized anxiety symptoms cannot “discriminate” between ‘psychosis’ and ‘generalized anxiety.’ Construct validity, oh such a dirty word for behavior analysts… is understood in “psychology” as a measure demonstrating both adequate convergence with expected measures and adequate divergence (discrimination) from measures that would not be expected to be highly related.

A common method of evaluating the construct validity of measures follows in a completely fictitious example below, this is the Multi-trait, Multi-method Assessment of Construct Validity. 

A psychologist at a mental health center develops a self-report inventory to assess generalized anxiety. Each new client at the mental health center is asked to complete this self-report inventory as well as a second questionnaire used to assess depression on two different occasions, separated by one month. In addition, two staff psychiatrists also conduct independent mental status exams with each new client and provide separate ratings of generalized anxiety and depression for each. Evaluate construct validity of the self-report inventory of generalized anxiety by interpreting all four sets of correlation coefficients within the multitrait-multimethod matrix that is obtained. Which, if any, of the four measures appears to possess adequate construct validity?

Instruments

Types of Validity

Self-report Measures

Convergent

Discriminant

Construct

Anxiety

.64 Y

.58 N

No

Depression

.41 N

.58 N

No

Psychiatrist Ratings

 

 

 

Anxiety

.64 Y

.37 Y

Yes

Depression

.41 N

.37 Y

No

 

According to the multitrait-multimethod matrix only psychiatrist ratings of anxiety show adequate construct validity. When working through the multitrait-multimethod matrix it becomes apparent that the self-report measures of depression and psychiatrist ratings of depression show too low a correlation with each other and thus do not have adequate convergent validity. As the correlation is low, it would appear that these two methods of measurement do not measure “depression” in the same way or that factors related to measurement (rater biases, etc) may be interfering with measurement. Convergent validity between the self-report measures of anxiety and psychiatrist ratings of anxiety does appear to be sufficiently high though, indicating that the two methods of assessing “anxiety” appear to be measuring the same construct (or at least closely related constructs) through different methods.

When one examines the discriminant validity of these measures using the multitrait-multimethod matrix it appears that self-report measures of anxiety and depression are too highly correlated for adequate discriminant validity. Basically, these measures appear to be measuring constructs that are too closely related (probably because they are both influenced by a third ‘construct’ and are only topographically different). However, the psychiatrist ratings of anxiety and depression do appear to show adequate discriminant validity. As the correlation between these two is low, it would appear that they do not measure the same construct.

When examining the construct validity of the measures, only psychiatrist ratings of anxiety has both adequate convergent and discriminant validity. When the correlations for discriminant and convergent validity for this measure are compared it also appears that there is a substantial difference between them. This indicates that psychiatrist measures of anxiety tend to be reliably correlated with other measures of anxiety and not with measures of other related constructs. Thus, psychiatrist ratings of anxiety are considered to have good construct validity. None of the other measures meets all the requisite conditions for construct validity. However, despite this good evidence for the construct validity of psychiatrist ratings of anxiety we cannot be entirely sure of the construct validity of this measure; we are, however, much better justified in making such a leap.  

If you like learning about methods or topics that expand your ability to understand the field of “psychology” as it relates to behavior analysis – sign up for our blog or leave us a comment below.

For those interested, here another example worked out of a multi-trait, multi-method assessment matrix. 

 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

The Four-Term Contingency

The Four-Term Contingency

by John Wesenberg, M.S., BCBA, LBA

                                                                                         The Four-Term Contingency

Behavior analysis has long been known as a field studying the three-term contingency (antecedent-behavior-consequence). More specifically, behavior analysis has tended to focus on overt/ observable behavior and how idiosyncratic reinforcement schedules (i.e., fixed, ratio) and the immediacy of reinforcement impacts behavior. Skinner has written extensively about the conceptual underpinnings of private events, although, experimental analysis of covert behavior has had a difficult journey into the scientific literature. Due to this, behavior analysis has been come to be known as the field in psychology that has neglected the study of thoughts, emotions, and cognition. For this reason and a few others, behavior analysis has ultimately been pigeon-holed into a field known as “autism therapy.” For behavior analysis to persevere and account for thoughts, emotions, and cognition, they must go beyond the three-term contingency and account for contextual variables within a person’s environment.

Establishing operations (EOs) were described most specifically by Michael (1993) as environmental situations that momentarily establish or abolish the effectiveness of potential reinforcing events, people, things, etc. and discriminative stimuli that evoke behaviors most likely to gain access to those potential reinforcers. The three-term contingency, since then, has evolved into the four-term contingency (EOs-antecedent-behavior-consequence).

When a person is deprived (motivating operation) of attention, they will engage in behaviors that have been previously reinforced with attention (e.g., conversing about symptoms of distress). The evocative effect of a therapist (discriminative stimuli) has now been conditioned as a reinforcer because it is now associated with the availability of social attention. Being satiated (abolishing operation) on attention has the opposite impact on behavior. Behaviors previously associated with access to attention (e.g., conversing about symptoms of distress) will temporarily not be evoked by the same discriminative stimuli (therapist). In clinical practice, it is important for the clinician to consider what their role is in these terms with clients as they may find that they are conditioning a socially deprived person to talk about symptoms to maintain social connection – with the therapist. A therapist should keep in mind whether they are shaping skills that transfer well into the world and whether the therapeutic relationship is continuing for reasons best in the interest of the client.

Sign up for our mailing list or check out our continuing education if you’d like to learn more about clinical behavior analysis or rule-governed behavior!

Reference

Micheal, J. (1993). Establishing operations. Behavior analysis. 16(2), 191-206.

 

The Matrix Viz: A functional assessment of verbal behaving

The Matrix Viz: A functional assessment of verbal behaving

Today I’m going to introduce a project that is one of many formulations of functional assessment we’ve been developing. The current formulation was first put to use more than a year ago with Benji Schoendorff, MSc and the Contextual Psychology Institute (CPI).

Below, you’ll see a data visualization built around “The Matrix” framework. The Matrix framework was developed some years ago by Kevin Polk, Benji Schoendorff, and others. It has gained quite a bit of popularity as a way to teach Acceptance and Commitment Therapy skills to both clinicians and clients. Use of The Matrix framework typically involves having clients or clinicians identify thoughts, feelings, and experiences and how they are oriented on the visual cross-hatch above. This is meant to help people begin to orient to important relationships between their behaviors and their experiences, without necessarily teaching the more elaborate hexaflex model of Acceptance and Commitment Therapy processes. In practice, most clinicians do not teach the skills taught in Acceptance and Commitment Therapy (ACT) by actually teaching the hexaflex to clients, but clinicians frequently start by learning this more complex model and trying to then translate that into how they work with clients. This is sometimes difficult for clinicians and can sometimes result in rather “canned” applications of ACT when clinicians are first mastering the model. Thus, the Matrix model is about teaching fluidity of process and flexibility in a way that often translates more easily.

This brings us to the Matrix Visualization that we’ll discuss today. What you are seeing, is best conceptualized as a tool to assist in the functional assessment of verbal behavior in the context of other behaviors you may observe from the client that are less difficult to track. We have used Ecological Momentary Assessment (EMA) and behavioral observations of other types to better situate verbal behavior (vocal or written) in the context of a functional analysis. 

The picture below is only one of many formats to make looking at many layers of verbal behaving and actual behavior of individuals in a way that can help us see the meaning of ongoing behavior, in context. The visualization below is simply an output (like a graph) that is the result of using Natural Language Processing (methods of using computer science to examine verbal behavior) to process written or speech behavior. These measurements and the content tagged in the written behavior are then fed into a real-time data visualization (using Tableau) to allow us to see a visual model of what is reflected in the written or vocal verbal behavior over a particular period of time. 

In this post, I will simply show the visualization and the source and describe what you are seeing.  To be sure, visualizing behavior through The Matrix format – is a matter of preference. Just as one can look at data in a bar graph or a pie chart, so too can we change the output format in which we display the ever-changing patterns of verbal behavior seen across time and context.

This visualization below is an example run on a piece of my own writing from an earlier post entitled, “RFT the Space-time of the Human Universe.” Here you will see a single moment of time of my own experience and verbal behavior reflected in the Matrix Visualization format. Though we have used this formulation in organizations that data is confidential. We’d also like to note that this work has evolved through a partnership with Contextual Psychology Institute (CPI). We greatly appreciate their continuing support of the development of this work.

The Matrix Viz
A tool to assist in functional assessment of verbal behaving within the larger context of a client’s behavior. This visualization is a data-driven analysis of verbal behavior only, again this would typically be used with other data about the client’s behavior across contexts to assist the clinician in functional analysis.

Though what the eye is frequently drawn to is the “content” level displayed, what should be attended to more fully is the movement of the content and changes in it over time. This snapshot gives us a brief idea of what of the likely functions of behavior across the time point covered by this writing, it should not in any way be considered a stable assessment of behavior (the writing period consisted of a few hours at most). To gain a better understanding of the function of behavior longer periods of communication should be analyzed and changes in the visualization noted. Further, change in quantitative form is useful to examine – but the visualization itself is meant to bridge some of the gaps encountered by clinicians and trainers as they attempt to use assessment to understand the ever-changing experience of their clients.

The assessment tool is driven by examining ideographic relating patterns, and to a lesser extent, the nomothetic functions of verbal behavior. This measurement is ideographic in the sense that it reflects patterns of relating specific to the individual, over the time covered. It is not based on the assumption of a normal curve of frequency or average levels of communication about a particular topic.

This measurement is nomothetic in the sense that at some level language has a shared cultural conditioning history, this is essential for it to function as a “language.” That is, if we don’t share enough of the same conditioning/relating history with regard to any word, sound, or group of words – then effective communication across individuals does not happen. Therefore, there is a level at which “content” based analysis does become relevant. For example, the concept of the verbal “self” (i.e., deictic relating) is based on the idea that the process of the verbal world speaking about us, identifying our experience, and of learning to speak about our experience ourselves – is fairly universal. The content that then becomes conditioned around the experience of the “self” is then identifiable by examining the language that ideographically hangs together around the content of “I”, “me”, etc. This is further supported by a significant body of research from others in related fields, such as Pennebaker who have extensively examined the function of pronouns using Natural Language Processing methods.

Further, though “universal” aspects of our language learning experience can be examined tagged to content, as mentioned above, most of the rest of the levels of analysis shown here is driven by vector-based Natural Language Processing methods. These do not assume particular content but instead look at changes in language by dropping to the level of semantic, syntactic, or statistical examination of the probability of a word/statement, etc following another word. Thus, rather than assuming normality around the frequency of a spoken word in a particular human context – they depend more on the underlying structure of language. This allows us to assume less about the content we expect and to pay more attention to the changing “signal” reflected in an individual or group’s “languaging” behavior. We can then use changes in the “signal” to understand what interpersonal, environmental, and other factors – constitute important contextual influences on the individual’s behavior.

At any moment, we relate on many levels of our experience. The “what” of what we relate is the layer most commonly assessed by psychological measures – it is by nature highly biased. “What,” we say is highly rule-governed and influenced heavily by contextual factors. It is well appreciated that our ability and willingness to report our experience moment-to-moment leads to significant response bias. Further, the methodology of asking about a specific “what” leads to efforts to standardize and statistically remove the influence of the questions themselves and other context. This is where the concept of standard error, etc. come into the creation of assessments. Assessing using a methodology that does not assume so many levels of normality, allows us to drop down to a lower level of analysis – a lower level of construct – and thus, hopefully, move closer to examining actual behavior and change – functionally.

This is akin to looking more at the  “how” of verbal relating, an indicator of experience. This is, in a way, similar to the difference between asking someone how much they hurt and instead of having them rate “0 (None) to 10 (A Lot),” listening to their expression about their pain from the warble in their voice or the strength of the words they use to describe their pain.

The Matrix Viz
An example of the Matrix visualization as tool for assisting in the functional assessment of verbal behaving.

What can we see from this visualization?

Notice that the content is not sorted simply by base level “content”. There are phrases that on a face level of “content” would likely appear to belong in another quadrant. This categorization of content is based more heavily on the surrounding context in which the content appears. This occurs through a “weighting” of semantic and syntactic writing features that “weight” the “how” of the context of that the content is used in over the outright content-based meaning of the word. In other words, the “latent” levels of relating show you the deeper levels of experience relative to the surface “content” levels. This means that “I” or other pronouns may show up in any quadrant of the visualization based on the deeper relating context that which “I” is used. It is not simply “I” that falls in the lower right quadrant. It is based on the individual’s use and experience that shows up repeatedly around that content. Similarly, the same “content” can be reflected in different colors and quadrants simultaneously and this reflects our continuously changing relations and/or relating at different levels to the same content during a specific time point. For example, if the individual experienced a level of conflict between a desire and its aversive consequences, this same content might show up in red and green and in different quadrants. For example, desiring alcohol but feeling that one should not engage in drinking – would lead the word “alcohol” or any word in the same semantic group used to mean it to show up in red and green, in quadrants reflecting this simultaneous difference in the “function” of alcohol for the person.

The words in this particular visualization are coded in red, green, and black. These are micro indicators akin to red = aversive, green = appetitive, and black = neutral. So, for example – you can see that in this visualization “personal experience” comes up as both “red” = and aversive, and yet, it is in the “Toward” half of The Matrix. This reflects that in the author’s experience at the time of this writing – the personal experience was likely aversive but yet being approached.

In the bottom right quadrant, you see indications of values – again, you must step around surface content to see that “dancing” is a semantic substitute for a value of “playfulness.” A clinician or consultant using the Matrix Visualization to guide assessment would not assume the meaning of “dancing.” They should use the visualization as a guide and query the particular meaning of the content with the individual. This is akin to what you might do in a clinical session, pick out the patterns in relating and try to understand their significance in both the individual’s life and their behavior. The clinician can then use this information to understand and quickly assess likely functions and to use that to guide questioning and to also use more clinically and personally relevant metaphors for use in treatment.

In the bottom left quadrant, “Thinking/Away” – the main noticeable characteristic is the volume of material that shows up, both aversive and appetitive material. Notably, the content is also highly intellectualized and a bit defused sounding. This reflects the author’s tendency to intellectualize.

In the top left quadrant, “Sensing/Away,” you see indications of experiences that fall in networks of relations that were being moved away from at this point in time. Again, this type of assessment is best used as a method for examining likely functional relationships, following up with questioning with the client, and further using the assessment over time to examine likely changes in functional relationships. Thus, this kind of assessment likely provides a great deal more clinical useful information to a clinician than the average measure of “symptoms” – that reflects little about the client’s interpretation of those symptoms, no information about how the symptoms functionally relate and relies on self-report survey methodology that by nature includes a high degree of response bias influence.

If you’re curious about Natural Language Processing as up and coming method of quantitative assessment in Contextual Behavioral Science – See our Resources menu.

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

A Beginner’s Guide to Clinical Behavior Analysis (CBA) and Related Treatments (ACT, DBT, FAP)

A Beginner’s Guide to Clinical Behavior Analysis (CBA) and Related Treatments (ACT, DBT, FAP)

A Beginner’s Guide to Clinical Behavior Analysis
If you’re interested in studying how to treat ‘mental health’ issues, as a behavior analyst, Clinical Behavior Analysis (CBA) is the pathway you should be looking into.

Clinical Behavior Analysis (CBA) is not a new area for behavior analysis, in fact, behavior analysts treating “mental health” issues pre-dates the refocusing of the field to the treatment of Autism. Clinical Behavior Analysis involves using learning principles to help people who often identify as having “mental health” challenges change their behavior and improve their functioning. 

What is Clinical Behavior Analysis?
Clinical Behavior Analysis (CBA) is at the intersection of behavior analysis and psychology. It is the application of behavioral principles to changing behaviors previously considered to fit in within the are of ‘mental health’. Clinical Behavior Analysis focuses on changing behavior through functional analysis and reinforcement of more adaptive behaviors. CBA requires evaluating the impact of multiple levels of contingencies on the client and determining which level(s) of contingencies to intervene on to create the most impact in changing the client’s behavior. Changing the client’s behavior – also tends to change the client’s experience. Application of behavioral principles to ‘mental health’ has existed since Skinner’s time; however, much of CBA fell out of popularity during the Cognitive Revolution within psychology. Now, with ‘psychology’ in a replication crisis born of the constructs and methods that allowed for rapid growth and division from behavior analysis – CBA is rising again in popularity.

History of Clinical Behavior Analysis
Clinical behavior analysis was developed during a time of rapid growth and change in scientific psychology. With a strong interest in data-driven treatment, John B. Watson and other early behaviorists began researching methods that could be scientifically verified. They turned away from early clinical work with mental health issues—and techniques that couldn’t be measured or observed—and toward controlled experiments. They laid down a foundation for understanding how different operant and classical conditioning might be used to treat behaviors considered “mental illness.”

During the Cognitive Revolution, Clinical Behavior Analysis as a clear arm of behavior analysis fell out of focus; however, treatments based on behavior analytic principles grew within realms of “psychotherapy” traditions. These treatments are now often confused as themselves being CBA. Examples of these treatments that fall into this category include Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Functional Analytic Psychotherapy (FAP). To be clear – ACT, DBT, and Functional Analytic Psychotherapy may be performed in ways that are CBA – but they are not by default CBA. It is entirely possible to do ‘canned ACT’ or to otherwise do what people recognize as one of these treatments without using functional analysis to guide treatment. In those cases, these treatments are not CBA.

Acceptance and Commitment Therapy as Clinical Behavior Analysis
Acceptance and Commitment Therapy (ACT) has become very popular with behavior analysts, particularly as Relational Frame Theory (RFT) and as a clinical behavior analysis recently. There is much current debate over whether “ACT” is clinical behavior analysis. This debate is well warranted as ACT though grown out of Relational Frame Theory and explicitly behavior analytic principles diverged to compete with cognitive-behavioral treatment packages. This necessarily led to a language that would fit training a multitude of clinicians (mid-level terms) and result in higher inter-rater reliability in Randomized Controlled Trials (RCTs) against Cognitive Behavioral Therapy (CBT). Most would say “ACT” accomplished its goals here and now is recognized as a treatment efficacious for the treatment of a wide variety of “psychological” problems right alongside its former chief competitor, Beckian CBT. Now – the issue becomes that most of the existing training on ACT follows the patterns set during this period. These trainings are meant for psychotherapists, use imprecise mid-level terms that tend to confuse behavior analysts, and do not well prepare behavior analysts for utilizing ACT in ways consistent with behavior analytic scope and practice. 

Functional Analytic Psychotherapy as Clinical Behavior Analysis
Functional Analytic Psychotherapy has its foundation behavior analytic principles as a way of improving in-session behavioral repertoires. The clinician then seeks to generalize these in-session improvements to the client’s outside-of-session life. In recent years, this treatment has also begun to go the way that ACT did to become better recognized as an effective psychological treatment. This has included, again, developing standardized terminology and even beginning to focus on a more specific set of clinical problems. This again – is well suited for the treatment becoming a competitor in “psychotherapy” according to standards of Randomized Controlled Trials (RCTs) but does not bode well for the training of behavior analysts in this treatment according to their scope and capabilities.

Dialectical Behavior Therapy as Clinical Behavior Analysis
Dialectical behavior therapy (DBT) is a form of therapy developed by Marsha Linehan, Ph.D., that emphasizes chain analysis, fading, and reinforcement of less dangerous behaviors in its population of interest. This approach has been shown effective in treating people who suffer from intense suicidal urges or self-harming behaviors like cutting or drug addiction. Despite how DBT has held to its roots somewhat more effectively than it would seem ACT and Functional Analytic Psychotherapy have – it is also in this writer’s opinion likely the most out-of-scope for behavior analysts simply due to the typical target applications of the overall treatment package. There are many places where topography can be picked up under supervision for behavior analysts and treatment methods may be taught consistent with behavioral principles and behavior analysts’ scope of practice. DBT applied to “borderline personality disorder” is well appreciated for its difficulty and danger in application. True “DBT” is performed with a team of clinicians, with a great deal of support, and is not for behavior analysts beginning to develop skills in Clinical Behavior Analysis. 

Clinical Behavior Analysis as Clinical Behavior Analysis
It’s because of the incompatibilities in how some of these treatments are now taught that I prefer to refer to Clinical Behavior Analysis as “Clinical Behavior Analysis.” If we are clear in labeling it differently, it will be easier for behavior analysts wanting training in ACT or other treatment techniques to find clinicians able to train them in ways consistent with their scope and behavioral principles. This does not again mean that one cannot learn the techniques used in “ACT” but that one will likely be learning them without the use of mid-level terms and with more precise and clear linking to behavior principles. 

 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

Finding Clinical Behavior Analysis: Part I

Finding Clinical Behavior Analysis: Part I

by Angela Coreil, PhD

In my recent invited talk at CalABA on Clinical Behavior Analysis as a way of unifying the behavioral sciences, I alluded to a series of painful learning experiences that brought me to Clinical Behavior Analysis.

My training path has been long and winding – all with the intention of finding ways to improve clinical treatment. You see, I grew up with a close family member experiencing a great deal of impairment, emotional pain, and later addiction. I was present for years of this family member seeking treatment and even as a child seeing failures in the systems meant to help her. I watched her go through the revolving door of inpatient units, which became like brief vacations to her. I watched as therapists seemed helpless to soothe her pain. And, I watched as she was prescribed pill after pill to ease her pain. I was at an early age effectively an involuntary ‘mental health’ crisis worker.

This led to a passion for understanding human behavior and a desire to find better ways to address human suffering. I believed that I could best influence treatment by becoming a process and outcomes researcher and set upon a long path to become this. I spent a number of years gaining experience on process and outcomes studies at a number of major research institutions in Houston, Texas where I lived. Then I happened upon on a job as a Research Coordinator for a project called “Opportunity Houston.” This was a large grant focused on treating dual diagnosis (mental health + addiction) homeless individuals. The study focused in some respects on enriching the environments of those experiencing addiction by providing housing and work, contingent on improving maintenance of sobriety. I later learned this was a study in part of Kelly Wilson’s design, an ACT founder. At the time, I would not have known who he was but the William “Dub” Norwood was my advisor there and he was an early ACT devotee.  

It was through him that I began to be exposed to ACT and then entered the University of Houston – Clear Lake for my master’s in Clinical Psychology. Following this, I started my doctorate in Clinical Psychology under Rob Zettle, Steve Hayes’ first student who played a strong role in developing ACT back when it was called “Comprehensive Distancing.” Throughout my master’s I found myself drawn to ACT, in its stance that human suffering was a natural part of the human experience and often an extension of otherwise adaptive behavior. In my early exposures to Beckian Cognitive Behavior Therapy, I was often presented with a list of ‘cognitive distortions’ and told that treatment would in part be helping clients recognize their ‘cognitive distortions.’ At the time, I found this conceptualization offensive and insensitive. I could not imagine myself telling other humans experiencing pain that their painful thoughts were ‘distortions’ of reality.

I would say that the way that clinical psychology training is currently structured – learning deeply the key elements of treatment is not an easy experience. We are typically taught behavioral principles but soon after we begin to divide off into camps to learn the particular language ways of our chosen orientations. I broke from this tradition repeatedly because beyond my allegiance to “ACT” was the guiding rule that my mission was to find ways to understand and improve treatment as a process researcher. I became more fluid in ACT treatment and began to depart from “canned ACT” in the early years of my doctorate. I had early experiences of clients with Obsessive-Compulsive Disorder” finding ways to “compulse” (momentarily avoid or reduce their anxiety) with the very ACT exercises I provided them. One client taught mindfulness, returned the next week to tell me how effective mindfulness had been in reducing their anxiety. I asked what had occurred and the client recounted engaging in mindfulness ‘instead of’ compulsions each time they became anxious. 

I went back to Rob and told him what had occurred and in his monotone way of beating a dead horse for my benefit he said ‘Yes, of course.’ And, then followed it with the ‘Hole in the Field’ metaphor to illustrate how I’d simply given the client a new shovel. Now, I would need to again – get them to drop their new improved ‘shovel.’ This was all in the context of learning Exposure and Response Prevention (ERP) also known within the behavior analytic community still as desensitization.

It was working in OCD and specializing in a particular technique that was widely endorsed across theoretical orientations as the ‘gold standard’ (i.e., ERP) for treating anxiety and related disorders that allowed me, I believe, to be able to track more about the differences in models as a I learned. After learning this technique well embedded in ACT, I sought out an Advanced Assistantship with the closest highly regarded research and treatment specialty center in Kansas. My clinical supervisor was widely regarded as a highly-skilled Beckian Cognitive Behavioral Therapy clinician and researcher. My initial learning experiences here were somewhat disorienting; however, as I went in with experience and skill validated by ACT experts. Fairly quickly into my training at this center, it became clear that ACT was not particularly favored by my supervisor and to treat clients under her supervision using similar language was quick to elicit punishment.

I remember writing back to my lab at that time and questioning whether I was actually proficient in ERP and ACT. The response I received was telling – but for years I did not fully understand the impact of what I was told in the full context of my academic experience. Rob told me that my ACT and ERP was fine and that I would simply have to ‘learn their language.’ He mentioned that as Steve Hayes’ first student he was also sent to work under the competing theoretical model for his internship year – under Aaron Beck. Though he never disclosed much about this experience directly it often seemed apparent that his internship year had probably not been easy on him.

I’d like to say that I won this particular CBT expert over; in fact, I learned the language and got out as soon as possible. I seemed to be fighting a battle far bigger than myself with zero footing as a new mother of a 4-month old just pre-internship. From here, I moved onto working at Rogers Memorial Hospital under Brad Reimann and running the day-to-day clinical management of an adult Intensive Outpatient Program for OCD in Oconomowoc, Wisconsin. By that time, I had mastered the CBT language and found myself commended and promoted for my treatment skill.

 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

Notes from CalABA 2022: A field ready for change.

Notes from CalABA 2022: A field ready for change.

by Angela Coreil, PhD

Fields Ready for Change: Notes from CalABA 2022

As I sit here today, recalling my experience of CalABA and the responses to talks, including but not limited to my own talk on unifying the sciences, it is clear that change is both needed and wanted. We find ourselves in a world where COVID has altered how we operate in our lives and in our world. We have found ourselves in the ‘Great Resignation’ of people leaving their positions and rethinking their priorities out of necessity.

I too have been on this journey. Long before 2020, I found myself embedded in a system of seemingly unworkable contingencies. This led to several years of inventing and reinventing myself and my career – and finally to freedom from the system that had held me down for a decade. It is from this perspective and with this experience that I find myself advocating for the field to be better, not because I am the right person to do so, but because I built myself a system that allows me to speak up more freely than most.

At CalABA 2022, I was able to speak at my first in-person conference since freeing myself from academia. I found myself re-invigorated by the presence, energy, and curiosity of those who attended my talk: Clinical Behavior Analysis: Unifying the Behavioral Sciences. It was inspiring to see how many people were already thinking about how to find a common language between behavior analysis and psychology and how many people were working in positions where they both needed and wanted more guidance on how to navigate the intersection between our fields.

There were a number of patterns that were evident in the responses of attendees. First, many were unaware that Clinical Behavior Analysis has existed since the 1950s. Second, the pervading thought was that additional degrees would help broach this gap – yet, those with multiple degrees broaching both fields still had the same questions. “Which hat am I operating under?”, “How do I know if I am still in scope?”, “Where does ‘ACT’ begin and end in relation to RFT and to the clinical situation I find myself in on a daily basis?” Many were struggling with how to speak to colleagues and stakeholders about the areas where our fields meet and divide. And, as I presented regarding the bubble forming as more behavior analysts enter the field and nearly all enter the Autism treatment area – there was recognition of how this affects the perception of behavior analysis, drives the narrowing of treatment programs, and ultimately will leave behavior analysts vulnerable to changes that are not under their control (e.g., changes in the DSM, etc).

Sign up for our mailing list or check out our continuing education if you’d like to learn more about clinical behavior analysis or rule-governed behavior!

 

Angela Coreil, PhD

Angela Coreil, PhD

Consultant and Educator

Angela J. Coreil, PhD works with individuals and organizations to promote better connected, purposeful, and effective living through behavior analytic principles. She has over a decade of clinical experience treating human suffering and promoting human excellence using Acceptance and Commitment Therapy (ACT) and other behavioral therapies. She now focuses on the promotion and translation of Clinical Behavior Analysis as a way to improve our science.

Defusion, ACT and RFT

Defusion, ACT and RFT

by John Wesenberg, M.S., BCBA, LBA

                                                                                         Defusion, ACT and RFT

A core process of Acceptance and Commit Therapy (ACT) is defusion. ACT processes by nature are often confusing for behavior analysts as they are not described precisely, and often cannot be. Defusion is often described assisting client in “creating some distance”, though momentary, from their thoughts and feelings that function as ‘rules.’ Defusion is meant to help the client contact direct contingencies when relating to verbal symbolic stimuli has become more dominant. In terms of Relational Frame Theory – defusion occurs when we alter the form, function, or frequency of a stimuli such that histories of verbal relating fall away and direct contingencies are briefly contacted.

For example, a popular exercise demonstrating defusion is the ‘milk, milk, milk” exercise. In this exercise, the clinician brings up “milk” and asks participants to think about milk. The clinician may then ask if in the process of thinking about “milk” whether the client is able to in some sense contact the taste, texture, or experience of their previous history with milk. Most individuals will report that they can contact “milk” though not present in the room with them now. The clinician may then engage the client in an exercise where the word “milk” is repeated in rapid succession, out loud, for a minute. Following this exercise – the clinician may ask what the client may have noticed about their experience of “milk” during and directly after the exercise. When the exercise has functioned as intended, the client will often report that they noticed things they had not before – for example that “milk, milk, milk” said repeatedly and rapidly sounds like “quacking” or that during the exercise they briefly ‘lost’ connection with their previous ‘experience’ of the taste, feel, etc of “milk.” Thus – defusion is meant to use the properties of verbal symbolic behavior to alter briefly which contingencies the client can track.     

Sign up for our mailing list or check out our continuing education if you’d like to learn more about clinical behavior analysis or rule-governed behavior!

 

Reference

Barnes-Holmes, Y., Barnes-Holmes, D., McHugh, L., & Hayes, S. C. (2004). Relational frame theory: some implications for understanding and treating human psychopathology. International Journal of Psychology and Psychological Therapy, 4, (2), 355-375).

 

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