Behavior Analysis in Practice

[Link]

SPECIAL SECTION: DIVERSITY AND INCLUSION

Cultural Humility in the Practice of Applied Behavior Analysis

# Association for Behavior Analysis International 2019

Abstract
Applied behavior analysis (ABA) has the intent to improve the human condition in a broad range of categories of practice and for
diverse groups of individuals across cultures. The data on the diversity of the professionals practicing in the field of ABA are
sparse. Access to ABA intervention is inequitable, and cultural differences are not adequately addressed in many current
established behavioral interventions. Cultural humility is a framework used by other professional disciplines to address both
institutional and individual behavior that contributes to the power imbalance, the marginalization of communities, and disparities
in health access and outcomes. This article discusses the adoption of culturally humble practices, specifically through the use of
self-reflection, by the field of ABA to address disparities and improve outcomes. A specific framework from the field of social
work is shared, and an adaptation to the behavior-analytic practice of self-management is provided.

Keywords Social service . Disability . Cultural humility . Applied behavior analysis . Self-reflection

Cultural humility incorporates a lifelong commitment to self- The concept and process of cultural humility is meant to
evaluation and critique to address power imbalances and de- replace cultural competence, because the term competence
velop mutually beneficial and nonpaternalistic partnerships denotes acquisition of knowledge of other cultures as an end
with communities (Tervalon & Murray-Garcia, 1998). Hook, goal that can be mastered, whereas cultural humility recog-
Davis, Owen, Worthington, and Utsey (2013) described cul- nizes and requires an ongoing, lifelong learning trajectory
tural humility as the “ability to maintain an interpersonal (Freshman, 2016). Cultural humility training was originally
stance that is other-oriented (or open to the other) in relation developed to educate physicians to work more effectively with
to aspects of cultural identity that are most important to the diverse populations (Tervalon & Murray-Garcia, 1998).
[person]” (p. 2). Multiple social movements (e.g., Me Too, Training in cultural humility has expanded to other profes-
Black Lives Matter, Stand Up) are actively acknowledging sional fields, including nursing (Fahlberg, Foronda, &
inequity and encouraging discourse to address injustice for Baptiste, 2016), social work (Fisher-Borne, Cain, & Martin,
disenfranchised populations and marginalized communities. 2015), and education (Nomikoudis & Starr, 2016).
Research documenting implicit bias by health care providers For the purposes of this article, the core elements of cultural
toward marginalized communities and its deleterious effects humility in Fisher-Borne et al.’s (2015) model—individual
has long been documented (Stone & Moskowitz, 2011; U.S. accountability and institutional accountability—will be used
Department of Health and Human Services, 2017). Within the as a framework for considering its application to ABA. This
field of applied behavior analysis (ABA), there is inequity in model assumes there are power imbalances that both individ-
who accesses effective behavioral interventions (Nguyen, uals and institutions must work to address through ongoing
Krakowia, Hansen, Hertz-Picciotto, & Ankustisiri, 2016) learning and critical self-reflection. Although Fisher-Borne
and in acknowledging that the design of behavioral interven- et al.’s model was developed for the field of social work, it
tions does not adequately address cultural differences (Fallon, is applicable to the work of applied behavior analysts. ABA,
O’Keefe, & Sugai, 2012). like social work, is dedicated to addressing socially significant
behaviors that improve the human condition (Baer, Wolf, &
Risley, 1968, 1987; National Association of Social Workers,
* Patricia I. Wright 2018). Behavior analysts have individual responsibility as de-
piwright04@[Link] fined by the Professional and Ethical Compliance Code for
1 Behavior Analysts (Behavior Analyst Certification Board,
NEXT for AUTISM, 1430 Broadway, 8th floor, New
York, NY 10018, USA 2017), and both fields have established institutions that deliver
 Behav Analysis Practice

social services, including nongovernment, government, and Ongoing Learning and Critical Self-Reflection Using
private agencies. Both professions have professional bodies Self-Management
guiding the science (e.g., the Association for Behavior
Analysis International, the International Federation of Social The models of cultural competence and cultural humility are
Workers), practice (e.g., the Association for Professional found outside of the field of behavior analysis; however,
Behavior Analysts, the Council on Social Work Education), behavior analysts are beginning to voice the importance of
and certification (e.g., the Behavior Analyst Certification cultural competence within their scope of practice. Fong,
Board, the National Association of Social Workers) within Catagnus, Brodhead, Quigley, and Field (2016) published an
their fields. Applying the constructs of cultural humility to initial paper on the topic that was stated to serve as a starting
the practice of ABA may afford the field improved effective- point for developing behavior analysts’ cultural awareness
ness and greater influence and promote equity in the distribu- skills. Beaulieu, Addington, and Almeida (2018) conducted
tion of care. a survey of 703 Board Certified Behavior Analysts to learn
about the extent of training for working with individuals from
diverse backgrounds, the perceived importance of training on
the topic, and the degree to which practitioners felt comfort-
The Application of Cultural Humility in ABA able and skilled in the delivery of culturally competent inter-
vention. The majority of respondents felt moderately or ex-
Professional Ethics tremely comfortable and reported they were moderately or
extremely skilled at working with individuals from diverse
The Behavior Analyst Certification Board’s (2017) backgrounds. However, the majority of respondents also re-
Professional and Ethical Compliance Code for Behavior ported having little or no training in cultural competence. This
Analysts references both language and culture: reported confidence without training may be indicative of a
need for behavior analysts to evaluate with greater scrutiny the
1.05 Professional and Scientific Relationships. application of cultural competence in their practice. One strat-
egy to address cultural competence and humility within the
(b) When behavior analysts provide behavior-analytic practice of behavior analysis is to review how other profes-
services, they use language that is fully understandable sional fields adopt culturally humble practices and assess the
to the recipient of those services while remaining concep- appropriateness of these practices for behavior analysis.
tually systematic with the profession of behavior analysis. Fisher-Borne et al. (2015) provide a framework for the
They provide appropriate information prior to service de- practice of cultural humility within the field of social work
livery about the nature of such services and appropriate (Table 1). The questions posed within this framework are
information later about results and conclusions. not operationally defined in a manner familiar to behavior
(c) Where differences of age, gender, race, culture, eth- analysts and require examination for use within the practice
nicity, national origin, religion, sexual orientation, dis- of behavior analysis. The well-established behavioral practice
ability, language, or socioeconomic status significantly of self-management (Cooper, Heron, & Heward, 2007) might
affect behavior analysts’ work concerning particular indi- be considered equivalent to self-reflection and used to develop
viduals or groups, behavior analysts obtain the training, culturally humble practices. Self-management requires three
experience, consultation, and/or supervision necessary to steps: (a) a clear definition, (b) data collection and analysis,
ensure the competence of their services, or they make and (c) delivery of consequences. For example, a clear defini-
appropriate referrals (p.5). tion may be that all clients have equal access to treatment,
regardless of socioeconomic status, race, or ethnicity. Data
This acknowledgment of the importance of language are then collected regarding clients attempting to access inter-
and culture within the Professional and Ethical vention, and those data are assessed for bias. The data can
Compliance Code affirms the importance of culture at measure the demographics of those attempting to access ser-
an institutional level to ensure professionals are working vice against the demographics of the local community where
within their scope of practice. There are sparse data on the practice is located. If bias is identified, strategies are then
the cultural diversity of behavior analysts. One paper developed to improve access and are then applied. If equity of
recently conducted an in-depth analysis of gender treatment access is a goal for the organization, these data
(Nosik, Luke, & Carr, 2018), but other areas, including might be reported publicly during staff meetings and included
race, ethnicity, sexual orientation, and religion, have not in the annual report, resulting in positive reinforcement for
been evaluated. Ongoing institutional and individual as- meeting the goal and serving the community and in punish-
sessment of those practicing ABA can be conducted to ment by providing public visibility of not achieving a stated
further determine where disparities exist. goal and perhaps the public perception of being
Behav Analysis Practice

Table 1. Individual and Organizational Questions to Assess Cultural Humility

Essential questions for critical self-reflection Essential questions to address power imbalances

Individual level • What are my cultural identities? • What social and economic barriers affect a client’s
• How do my cultural identities shape my world view? ability to receive effective care?
• How does my own background help or hinder my • What specific experiences are my clients having that
connection to clients/communities? are related to oppression and/or large systemic
• What are my initial reactions to clients, specifically to issues?
those that are culturally different than me? • How do my practice behaviors actively challenge
• How much do I value input from my clients? power imbalances and involve marginalized
• How do I make space in my practice for clients to communities?
name their own identities? • How do I extend my responsibility beyond individual
• What do I learn about myself through listening to clients and advocate for changes in local, state and
clients who are different than me? national policies and practices?
Institutional level • How do we organizationally define culture? • How do we actively address inequalities both
Diversity? internally (i.e., policies and procedures) and
• Does our organization’s culture encourage respectful, externally (i.e., legislative advocacy)?
substantive discussions about difference, oppression • How do we define and live out the core social work
and inclusion? value of social justice?
• How does our hiring process reflect a commitment to • What are the organizational structures we have that
a diverse staff and leadership? encourage action to address inequalities?
• Do we monitor hiring practices to ensure active • What training and professional development
recruitment, hiring and retention of diverse staff? opportunities do we offer that address inequalities
• Does our staff reflect the communities we serve? and encourage active self-reflection about power and
• Is our leadership reflective of the population/ privilege?
communities we serve? • How do we engage with the larger community to
ensure community voice in our work? What
organizations are already doing this well?

Note. Reprinted from “Mastery to Accountability: Cultural Humility as an Alternative to Cultural Competence,” by M. Fisher-Borne, J. Caine, and S.
Martin, 2015, Social Work Education, 34, p. 176

discriminatory. This is an example of self-reflection for insti- primary reason the child has had a reduction in aggression is
tutional accountability. the school’s commitment to trauma-informed care and that the
Self-reflection can also be used for individual accountabil- educators are all now taking a trauma-informed approach in
ity, including private events. For example, when prejudicial their interactions. The behavior analyst perceives that it is a
thoughts occur during treatment with clients, I will vocalize result of functional communication training and systematic
these thoughts to my supervisor during our supervision meet- reinforcement. The behavior analyst is aware that collabora-
ing and commit to assessing my bias and attempting to re- tion in a transdisciplinary team can enhance the quality of
move that bias from my behavioral repertoire. Data can again services provided, but this behavior analyst has received lim-
be collected and analyzed on this individual behavior to assess ited training on collaboration during preservice and in-service
for change and success or lack of success of the intervention. training (Kelly & Tincani, 2013). The behavior analyst shares
Individuals can record and report their frequency of prejudi- with his supervisor that he does not understand the expertise
cial thoughts during their hours of practice. Positive reinforce- and cultures of the other disciplines on the team and how they
ment and punishment for this behavior can be provided came to the conclusion regarding the child’s outcomes.
through the social praise of a supervisor or through a written Applying self-reflection requires the behavior be defined; in
goal on a professional improvement plan. This is an example this case, it might be a professional goal set with a supervisor of
of self-reflection for individualized accountability. improving collaborative behaviors by identifying opportunities
Consider the following examples to further illustrate the for cross-training with other disciplines (Donaldson, Stahmer,
application of self-reflection to promote cultural humility into Nippold, & Camarata, 2014). The behavior analyst requests
the practice of ABA. and attends training (preferably a competency-based training)
in trauma-informed care to learn about the principles of the
Case 1 A transdisciplinary team including a speech-language practice and better discern the perceived effect it is having on
pathologist, educator, behavior analyst, and school psycholo- the challenging behavior. Data are collected on training atten-
gist are collaborating to support a student exhibiting aggres- dance and competency outcomes, and the behavior analyst re-
sive behavior toward others in the classroom. All members of ceives reinforcement from his supervisor for attending a cross-
the team agree that the student’s behavior is improving. The discipline training. In addition, the behavior analyst, through
psychologist and educator have verbally stated that the attendance at the training, is now able to interpret the
 Behav Analysis Practice

nonbehavioral terms of trauma-informed care (e.g., promoting analysis is early in its application of culturally humble prac-
a safe environment) into behavioral practices (e.g., environ- tices to the field. We can take advantage of principles and
mental arrangement as a setting event). An understanding of strategies developed in other professional fields and tie our
the behavioral principles of trauma-informed care to which the behavioral practices to their frameworks so that behavior an-
other team members are attributing the student’s success might alysts can improve their culturally humble practices.
lead a behavior analyst to want to describe the observed effects
in behavioral terms. However, use of behavior-analytic terms
can create a barrier among team members without behavior- Discussion
analytic training, as behavior-analytic language can be per-
ceived as harsh or unpleasant (Critchfield et al., 2017). The field of ABA strives to achieve greater influence and
Refraining from reframing the practice in behavioral terms improved outcomes in the application of the science.
may increase the likelihood of positive interactions with other Disparity in the application of ABA exists. The application
team members while collaborating on this case. of cultural humility to the ongoing practice of ABA may me-
diate this disparity and improve outcomes. There are limited
Case 2 A behavior analyst who was raised in a family of upper data regarding cultural bias within the practice of behavior
middle-class socioeconomic status and who currently makes a analysis. This article relies heavily on the practice of cultural
salary 400% above the poverty level for her geographic area humility exhibited by other professional disciplines. The cur-
of residence is providing parent training to a family whose rent social movements calling for change are encouraging
financial status is below the poverty level. The training is to discourse within the field of behavior analysis. If ABA is
support the family’s engagement in generalizing activities of going to expand its influence and ensure equal access, critical
daily living into the home environment, including the promo- self-reflection and behavior change are necessary. Utilizing
tion of independent eating and dressing. The behavior analyst self-reflection may be a first step to analyzing both individual
shares with her supervisor that the family is not following the and institutional behaviors that are limiting the effectiveness
treatment plan by purchasing the items suggested for indepen- of the application of ABA.
dent meal preparation, including microwavable prepared The field of behavior analysis is committed to using data to
meals, nor have they purchased the suggested clothing, in- understand, motivate, and measure behavior change.
cluding elastic-waist, pull-up pants. She is concerned about Institutional data on the current cultural diversity of practi-
the family’s lack of compliance with the suggestions and tioners can be measured and reported regularly. This might
worries that they are not committed to participating in include the voluntary and self-reported identities (e.g., gender,
treatment. ethnicity, sexual orientation, socioeconomic status) of those
Improving cultural humility through self-reflection is acquiring certification in behavior analysis and those attend-
targeted as a professional improvement goal for this behavior ing events catered to behavior analysts (e.g., conferences, con-
analyst. The supervisor and behavior analyst define the behav- ventions, group continuing-education events), as well as at
ior change for self-reflection; during supervision, the behavior their career milestones (e.g., fellowships and board appoint-
analyst will vocally and in writing list the factors that may ments). These data could inform us of the characteristics of the
contribute to a family’s noncompliance with treatment goals. current membership. An institution delivering behavior-
The baseline data are the initial lists created by the behavior analytic services can conduct a review of self-reported demo-
analyst compared to the lists postsupervision, when the super- graphics of its professionals and clients to determine if the
visor assists the behavior analyst through professional learn- institution sufficiently represents its local community. If there
ing to develop an understanding of the multiple cultural and is disparity, implementing alternative recruitment processes
financial barriers, including lack of understanding of socio- can address the lack of diversity. Professional learning can
economic barriers, that would preclude a family from purchas- be offered in cultural humility, and a supportive environment
ing expensive food items and limit their ability to purchase that affords opportunity for discourse regarding culture can be
new clothing. Positive reinforcement can be provided for in- fostered. Behavior-analytic service organizations might also
creasing the frequency of items listed as barriers, for identify- consider utilizing the National Standards for Culturally and
ing alternative targets for treatment, and perhaps for sharing Linguistically Appropriate Services (CLAS), developed by
this learned experience with other behavior analysts as a peer the U.S. Department of Health and Human Services’ Office
educator. Negative consequences could result in required at- of Minority Health, as an assessment tool to measure their
tendance at a professional learning event and increased super- institutional adoption of culturally humble practices (Koh,
vision when the behavior analyst is treating families with sig- Garcia, & Alvarez, 2014).
nificantly different socioeconomic statuses than her own. This introduction to cultural humility is intended to be a
Establishing a cultural humility repertoire requires training starting point for applying the concepts to the practice of ABA
and ongoing professional learning. The field of behavior with the use of self-reflection as an applied practice. A
Behav Analysis Practice

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