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.

 

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).

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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.     

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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).

 

Rule Governance and the use of Values to Facilitate Exposure for OCD

Rule Governance and the use of Values to Facilitate Exposure for OCD

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

Rule Governance and use of Values to Facilitate Exposure for OCD

Behavior is dynamic and influenced by many contingencies simultaneously. Relational Frame Theory (Hayes et al., 2001) is an extension of behavior analytic principles to the human ability to learn language/symbols and the affects of these over-riding behavioral repertoires on our behavior. This extension accounts for much of human psychopathology that had defied previous parsimonious behavior analytic explanations.

“Values” are verbal constructions of meaningful directions for our lives. For example, a person may value “being a warm father.” This is by nature something that can never be “completed” but we can also always act in accordance with this statement. Orienting to values can serve as a motivating augmental. That is, the stimulus functions of a particular stimulus may be augmented to make them more or less salient.  For example, changing a diaper may for most be a rather aversive experience but for the father who holds the value of “being a warm father” and brings this to the experience of changing diapers – diaper changing may be transformed to almost an enjoyable task!

Within the clinical context, treatment of Obsessive Compulsive Disorder may be facilitated through presenting stimuli that remind the individual of their values at key points during exposures. For example, an individual who engages in excessive washing/ cleaning compulsions due to contamination concerns may be ‘stuck’ in a loop of avoiding an aversive experience in the short term through compulsions (e.g., excessive bathing and grooming). If this individual values “being a warm father” as described above – this may be used to help facilitate new flexibility in his behavioral repertoire in the presence of normally aversive and avoided “contamination.” For example, in treatment the father may be asked to engage in exposures that involve changing mock or real diapers. The client may normally rate this as a “7” on a scale from “[not anxiety provoking at all] 0 to 10 [extremely anxiety provoking]” normally. The clinician can present the task in the context of conversation that prompts the client to attend to their values, for example “John, I know that you value being a warm father. Does loving your child and caring for them warmly mean that you will care for their basic needs?” “Can you bring your love for your child into this moment to help you move towards what matters most?” [Note: All examples are by nature topographical and function of these statements must be assessed and applied ideographically, rather than topographically.] If these statements function as a motivative augmental for the client – the client may report that their starting anxiety rating lowered, “I know that I said this was a ‘7’, but now it feels like a ‘5’ when I think of my son.” Additionally, you may see that the client is more willing to approach, maintain contact, or resist compulsions – as the aversive functions of ‘contamination’ are augmented to a more workable range for 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

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).

Hayes, C. S., Barnes-Holmes, D., & Roche, B. (2001). Relational Frame Theory: A Post- Skinnerian Account of Human Language and Cognition. New York, NY: Kluwer Academic/ Plenum Publishers

 

An ACT Approach to Adolescent Suicide

An ACT Approach to Adolescent Suicide

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

 

Exposure to Privilege

Exposure to Privilege

The Function of Privilege within Our Science and Beyond

Angela Cathey, MA, LPA

If you’re familiar with my writing or social media, you are probably familiar with my tendency to advocate for the underrepresented and disempowered in our society. Recently, I’ve found myself in a Facebook debate about this, in my social feed, that warrants a more elaborate response. I am also a woman, in a science dominated by men in power positions, who continually seek to ‘educate’ me further when I disagree with them. So, read this post with all that in mind.

First, I’d like to acknowledge that posts on Facebook conversations are not an adequate medium for debate. Without our voices, without posture, and without other cues that reflect the complexity of our perspective we are virtually guaranteed to keep arguing even when we agree. Our specific wording, the individual’s perception of us, and the nature of the media itself are likely to drive the other’s responses more than what we’re intending to express. This is simply a result of how the contextual variables inherent in social media (e.g., anonymity, slow responsivity, lack of complexity, and a public venue) tend to function for us.

We are faceless, sometimes nameless, words on paper expressing complex ideas in bumper sticker length responses. This is in part why social media results in long, sometimes heated, and often pointless debates so frequently. We are not faced with the person behind the idea, the whole idea, cues about the person’s emotion – and are left responding mostly to our relata and words that are themselves varied in function. We miss the complexity of other’s ideas, knowledge, and experiences. This is, in large part, how words, and people, function out of context.

The post I made that began the debate was a repost of a USA Today post, entitled “All college students should take a mandatory course on black history and white privilege.” I will attempt not to recount the debate here in detail, name the individual, nor shame the individual for their perspective. I choose to believe that the individual is arguing because they, like myself, believe that our science can do a better job of moving the world forward. I choose to see us as on the same side. What occurred in the debate; however, encapsulates why I believe that our society needs “mandatory” exposure to the ideas and experiences of others and the impact of “privilege.”

We are all privileged and disadvantaged in some ways; however, those with less power in our society frequently have no way to express their perspectives without it being perceived as punishing to the majority. This is, in part, the essence of privilege. Those with power and privilege see their perspective represented all around them in their everyday experience. Those with power and privilege are more likely than those without, to be surrounded by people and experiences that reinforce their beliefs about themselves and others. Those without privilege are faced with few representations of themselves, punishing representations of themselves by the majority, and to find themselves represented in and responded to – as caricatures.

In some ways, being an underrepresented minority in like attempting to express complex ideas, about heated topics, on social media. The underrepresented are prone to be responded to based on relata. The complexity of their ‘selves’ (instead of their idea) responded to with hostility because their ‘otherness’ does not fit neatly into the boxes of those with the dominant view.

This is the influence of verbal symbolic rules, how they function interpersonally, and why I believe we should all be constantly exposed to the perspectives of others. We, in particular, need experiential exposure to minority perspectives in as many forms as possible. Some of these are going to be punishing for us, some of them are going to be overwhelming, and some of them are going to be affirming. And, we need to realize as a society that all of this is important for us to experience for our collective good. A course in white privilege or black history is a drop in the bucket. It may function for many aversively, and yet, we have to start embedding the minority experience in the lives of the majority. We are a society moving further and further away from complexity and existing in worlds that function as echo chambers. Within social media, within science, and within society – most of us have the privilege of being able to ‘unlike’, ignore, and benefit from the inherent reinforcement of our views from the dominant representations of our views surrounding us.

This is why exposure to the perspectives of disempowered minorities must be in some way “mandatory.” The coherence of those with significant privilege, in any form, is reinforced simply by existing in a world that endorses their perspective on nearly every level of their existence, all day, every day. The privileged have no reason, on mass, to decide to hear and appreciate the complexity of the minority experience. It tends to violate the sense of ‘self’ of the privileged to even hear that they/we are privileged. My colleague who debates me recognizes this and yet misses the complexity of my argument for mandatory exposure to the perspectives of minorities and our privilege.

True recognition of privilege and the perspectives of minorities that will create change means creating interventions that are embedded throughout our society. It means that media is created by minorities, it means that representations of the perspectives of minorities are embedded into our society in so many ways that they become not the expressions of an unknown caricature “other” but as part of our collective view of ourselves, our history, and our ability to change, together.

And, for the one who inspired the post, if the complexity of my perspective results in further attempts to correct me by insisting I simply need education on the basis of our science, on my feed, don’t be surprised if you get a more explicit public lesson on male privilege in our field and how your behavior functions aversively as ‘mansplaining.’ I am the female owner of a behavior analytic education site who disagrees with you, insisting that I need to educate myself in single-case design, reinforcement, and punishment because I disagree with you –  without stepping back to consider the context surrounding your behavior is an act of privilege in action.

 

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