Selecting Behaviors of Clinician and Community in Support of Sustainable Implementation
Tim Moore, BCBA-D
University of Minnesota Medical School, Minneapolis MN
“… we can introduce new cultural practices … but we must wait for selection to occur” (Skinner, 1981)
Applied behavior analysts today are fortunate to work in a time when making meaning of individual units of behavior involves ever-broader consideration of the contexts in which they occur. Our literature reflects a widening lens from discrete behaviors to peer groups, from classrooms to schools, from families to communities, and from communities to organizations and social structures. These concentric circles of influence contain facilitators and barriers to the adoption and sustainability of new behavior, the extent to which quality of life improves, and the equity of these experiences. Recognizing this complexity, whether in a Skinnerian four-term contingency or Kantorian interbehavioral field, elevates our level of responsibility and challenges us to make systematic adjustments to our analytic framework. Central to this challenge is locating our professional behaviors within the constellation of facilitators and barriers, engaging in developmental practices that better situate us as effective partners with those we endeavor to help, and striving for equity in our applied work and its outcomes.
This article is nominally about treatment adherence, which at its core involves a person carrying out one or more discrete behaviors, but ultimately it is about how behavior analysts steward the development of sustainable health behaviors within a framework of equity. Such stewardship involves appreciation of the layers of influences over the choices and practices of the consumers of our services, influences which include our own professional behavior. Describing this stewardship weaves a cloth from several threads related to our developmental trajectory as behavior analysts alongside our efforts to develop new and sustainable behavior for and with the individuals and communities we are privileged to support. The mechanics of weaving on a loom include separation of the elements at some stages of the process, prior to the points at which they come together, time and again, in gradual formation of the product. Achieving functionality and beauty from the loom relies upon the totality of this process.
Adherence Defined
As catalysts of change, applied behavior analysts have developed and studied approaches to skill development and reduction of challenging behavior. They have fit laboratory-derived principles to socially-significant human problems, and extended our technology to implementation by people without formal training in our discipline. A core objective in this branch of ABA is to achieve durable behavior change within natural communities of support. Implementation of treatment regimens by incumbents in the natural environment, in the absence of clinical oversight, is adherence to that treatment. It is important to distinguish adherence from observed behavior, which behavior analysts typically refer to as treatment integrity or fidelity. These terms are often confused in our literature, and it is helpful to clarify adherence as the extent to which behavior not under direct observation is consistent with the agreed-upon plan developed with the clinician. A significant body of literature in healthcare over several decades, including in applied behavior analysis, documents lower rates of treatment adherence are to be expected relative to observed treatment fidelity. This is not purely an academic matter nor is it trivial – substantial costs to individuals and the healthcare system result from non-adherence. People and families experience stagnation or deterioration in quality of life, unnecessary additional clinical encounters place undue burden on the system, and overall expenditure on healthcare continues to increase. According to the Kaiser Family Foundation, in 2020 non-optimized medication therapy accounted for 16% of $4 trillion in annual US healthcare expenditure – which does not include non-medication therapies (psychotherapy, behavioral supports) to which people also do not optimally adhere.
Adherence Contextualized
Concurrent with the challenges to enhancing treatment adherence, behavior analysts have embraced a culture of continuous improvement of our own behavior, most obviously within our evolving professional standards and regulatory mechanisms, but more importantly have become increasingly aware of the social contexts in which our professional activity occurs. The special issues of Behavior Analysis in Practice on Diversity, Equity, and Inclusion (2019) and systemic racism (2022), along with periodic updates to the Task List and Ethics Code of the Behavior Analyst Certification Board® (BACB®), reflect both a maturing recognition of our interdependent relationships with the people and communities we serve and a responsibility to nurture the principles and technologies of our science in context.
In the nearly quarter century since the publication in 2000 of Allen and Warzak’s seminal behavior analysis of non-adherence to treatment, the study of adherence has moved beyond proximal training conditions and the effects of reinforcement to include the familial, relational, societal, and cultural variables that impact the degree of engagement with professionals in the healthcare system (within which many behavior analysts function). Recent publications related to adherence in ABA services reflect a growing awareness and importance of contextual factors within which our technology can flourish or languish. These include Katherine Brown and her colleagues writing on family-centered practices; the descriptions of compassionate care by Bridgett Taylor, Jessica Rohrer, and their respective research groups; and Elizabeth Hughes-Fong and her colleagues’ highlighting critical perspectives and skills in cultural awareness and competence. In these contexts, the most impactful supports can be collaboratively designed, consumers of behavior change technology can make commitments to targeted behaviors they are more likely to keep, and the likelihood of socially significant impact increases. In a recent paper describing a behavior analytic model to enhance adherence, Rick Amado and I attempted to reflect these principles in specific guidelines for tailoring strategies to individuals within their unique circumstances.
It is indeed encouraging to witness the evolution in our field’s ability to identify variables that directly and indirectly influence the likelihood of implementing behavior analytic treatments outside of clinical settings. These principle-based advances in our formulations of implementation and social significance are consistent with the conceptualization of evidence-based practice in ABA, described by Timothy Slocum and his co-authors as verb rather than noun, a decision-making process within which the best available evidence in the treatment literature is synthesized with clinical experience alongside the values and lived experiences of consumers. The authors connect their definition to the founding of ABA and the concept of “applied” as described by Baer, Wolf, and Risley, as well as Wolf’s extension to the principle of social validity. In this light, taking steps to enhance and measure treatment adherence represents contemporary advancement for behavior analysts while recognizing a firm grounding in the history of the field.
Adherence through the Lens of Health Inequity
As important and hopeful as this progressive evolution in our literature has been, we should be careful to hold it in dialectical tension with the present reality of disparities in access and adherence to healthcare, including behavior analytic treatment, among minoritized and underserved communities. The special issues of Behavior Analysis in Practice noted above are important resources for self-reflection and reckoning with the presence and impact of racism and inequities experienced by the people and communities we support and work alongside.
With regard to adherence specifically, Elizabeth McQuaid and Wendy Landier describe how the healthcare ecosystem perpetuates inequity in treatment follow-through at individual and systemic levels. Of course, behavior analysts are active participants in this ecosystem. Individual providers are prone to implicit bias in words and actions, and often do not appreciate the impact of lifetimes of real and perceived discrimination, culturally rooted beliefs about disease and disorder, and perspectives about available interventions. Healthcare provider organizations and larger systems are not only the contexts within which individual behavior analysts train and practice professionally – as institutions they are prone to propagate biases and limitations that perpetuate inequities.
With careful attention to these common shortcomings of individuals and systems, McQuaid and Landier suggest how adherence to care regimens by minoritized and underserved communities can be improved. Individual providers can work in close partnership with the people they serve to adapt empirically supported adherence enhancement approaches based on cultural norms, preferences, and language. To facilitate this capacity, individual providers are directed to pursue substantive training in cultural awareness, patient-centered communication, and in recognizing and addressing implicit biases. Organizations are called to recognize disparities in access and utilization, to creatively involve culturally connected community healthcare workers to promote adherence, and to ensure culturally relevant measurement of therapeutic alliance and the effectiveness of shared decision-making. At the system level, recognize that the choice to access care (or not) is influenced by a complex set of interrelated contemporary and historical factors, which are differentially experienced between privileged and underserved groups. Contemporary factors include, for example, geography, insurance coverage, job flexibility, child care, and transportation. Historical factors include experiences of racism or otherwise suboptimal interactions with providers, organizations, and the larger healthcare system, family patterns of healthcare utilization, and mistrust in systems stemming from lived experience and generational transmission. Interested readers can consult the comprehensive 2023 review on this topic by Isha Metzger and colleagues.
Framing Adherence and Equity within Principles of Selection
In Selection by Consequences, Skinner suggests that when effective behaviors are available but not emitted, it indicates they were not selected for by prevailing contingencies that support the survival of the group. People observe and enact particular practices because “groups which induced their members to do so survived and transmitted them” (p. 503). Skinner’s wisdom here is relevant in the consideration of our professional behavior as well as behavior involved in the development and implementation of care regimens by the people we serve.
If behavior analysts are called to enhance equity through a future of optimizing self-awareness and growth, influencing the systems within which we work, and better understanding the preferences and choices of the diverse people and communities we serve, we would do well to examine how our professional culture can promote this evolution. Our professional organizations (e.g., Association for Behavior Analysis International, Association for Professional Behavior Analysts, state ABA chapters), credentialing authorities such as the BACB®, academic departments, editorial boards, workplaces, and other brokers of behavior analytic culture all induce or constrain behavior at the level of the individual. As we encourage ongoing and robust dialogs in our literature, conference spaces, meeting rooms, and break rooms, behavior analysts in leadership positions might reflect on Skinner’s guidance that people do not solve problems raised by circumstances they find themselves in, rather “the circumstances select the cultural practices which yield a solution” (p. 504).
Likewise, the healthcare practices and choices of the people we serve are many and layered, and at least in part transmitted culturally. Choices include whether or not to make an appointment with a doctor when flu symptoms strike, to seek a mental health professional when anxiety or depression degrades quality of life, to consult with a behavioral professional when aggression or destruction are taking a toll on family functioning, to trust that provider, to fully engage in partnership, and to adhere collaboratively developed treatments. Our assessment approaches may need adjusting to accommodate a perspective on cultural-level influences over discrete behavior.
Saini and Vance framed selection at the group level in terms of interlocking behavioral contingencies (IBCs) involving multiple people, the products of the interlocking contingencies, and the consequences (i.e., metacontingencies). Thus, IBCs are the unit of analysis at the level of cultural selection, in contrast to individual behaviors in operant selection. Recent IBCs related to the advancement of our field toward cultural awareness and health equity include calls for papers for the special issues of BAP (2019, 2022), establishment of a Diversity, Equity, and Inclusion board within the Association of Behavior Analysis International (ABAI), and the creation of a Diversity designation of submissions to the ABAI annual convention. These IBCs may generate products (such as a more diverse behavior analysis workforce) and cultural consequences (such as greater access to care for minoritized and underserved populations). These products and consequences may then reflect the primacy of cultural grounding in our work and equity in our outcomes, support similar behaviors over time, and contribute to durable features of our professional environments. Improved metrics of adherence to care regimens may also follow as a product of these IBCs. As Skinner reflected in The Phylogeny and Ontogeny of Behavior, “many of the complex phylogenic contingencies which now seem to sustain behavior must have been reached through intermediate stages in which less complex forms had lesser but still effective consequences” (p. 671).
Future Directions
Exactly how our professional behavior will be shaped over time is difficult to predict. Arranging for contact with new contingencies can enable behavior analysts to align emerging values with opportunities for new behavior. Victoria Burney and her colleagues recently called for researchers in our field to incorporate qualitative methods to enhance the social validity of our work and expand our range of inquiry to fit existing and emerging needs where the science of human behavior can contribute unique value. Qualitative inquiry is a central feature of Community Based Participatory Research , an approach to co-creating research with stakeholders from the initial questions through the methodological design to the interpretation of results. Behavior analysts have long considered the role of community partnerships in research as important, though few in our field have chosen to learn and apply qualitative methodologies as vehicles to open up new avenues for focused listening and learning. As Malika Pritchett and her colleagues remind us, power imbalances in our research have persisted in the absence of full partnership between behavior analysts and those with whom we study and apply our science.
Learning through inquiry in full partnership with individuals and communities can lay the groundwork for the collaborative development of supportive interventions in creative ways that optimize evidence-based practice and the likelihood of adherence to treatments. More broadly, such an approach could promote interlocking behavioral contingencies whose products and consequences select behaviors perpetuating a culture of shared inquiry and steps towards healthier lives. In their recent paper, Brandon Khort and his colleagues reflect these possibilities in their model of community initiated care. Their model bridges the principles of Community Based Participatory Research and the application of interventions based on shared learning that fully leverage the unique strengths, resources, and practices in communities. Calls for integrating formal and informal systems of care to enhance efficiency and reduce costs are not novel. For example, Anne Rogers and Rod Sheaff describe these ideas in the context of the United Kingdom’s National Health Service. These sentiments are echoed by others who envision great potential for sustainable interventions in healthcare when they are firmly rooted in, and owned by, the communities within which they are meant to confer benefit.
Conclusion
The future contributions of behavior analysts toward a society in which health equity is a reality will be a function of our effective participation in a cycle of continuously aligning our behaviors with consensual values. We are faced with the simultaneous challenges of evolving the culture within which we apply our science, and co-creating the conditions for the development of, and adherence to, behavior change interventions alongside the people and communities whose lives can benefit from our technology. Through robust participation in our longstanding interlocking contingencies – as writers and readers of publications, speakers and listeners at conference presentations, leaders and members of committees, organizers and attendees at state chapter meetings – we will observe how our professional culture succeeds or fails to induce behaviors reflecting progress toward individual, organizational, and systemic changes that weave the threads of our stated values into cloths of practice.