Kings X

I’m guessing that if you’ve shouted “Kings X!” while playing with friends, this means you are of a certain age.  When I was a child, this was the same thing as yelling, “Time out!”  This got you a momentary suspension of the game while you argued over the rules, checked to see if your friend really was hurt, or ran inside to go to the bathroom.  I haven’t a clue what kids say today.  Maybe they just press the pause button.

This blog is generally about how we talk about behavior, and most posts focus on a conceptual nicety of some sort.  However, this time I’m asking for a break from this agenda – a temporary suspension of the game – so I can wander into somewhat different territory.  If I’d used “Time out” as a title, you would have understandably expected a different topic.  What I am writing about this time concerns how we approach clinical practice.

A common post on the “Students of Applied Behavior Analysis” Facebook page asks for guidance about ABA studies that have been published on a particular topic – usually a specific type of behavioral problem.  This kind of request warms the cockles of the old professor in me.  We want to train budding young behavior analysts to respect the value of the peer reviewed research literature and use its guidance in their clinical practice.  Making it up as you go isn’t a clinical style that will be good for our field in the long run.  On the other hand, slavish dependence on published studies can be limiting when the right ones aren’t available, and no study provides all the right answers for each clinical situation anyway.  Some may not even deliver on their promises.

Can a reliance on published studies be over done?  Are programs teaching students to just plug in procedure X for problem Y, instead of thinking through the variables and making a considered and unique judgment?  To what extent should ABA practitioners be comfortable designing intervention procedures based on their cumulative training and experience without specific studies to tell them what to do?

How well are we training our students?

Our understanding of the basic processes underlying operant behavior is comprehensive and demonstrably powerful.  The foundation of ABA procedures in operant learning principles is what sets our field apart from other approaches to managing behavior.  The BACB requires at least 45 hours of this content – a modest but decent foundation.  We should be under no illusion, however, that each such course offered across all ABA programs provides the best treatment of basic principles that this literature allows.

Then there are all the other BACB curriculum requirements for approved course sequences.  Extensive training in the applied literature is a prominent part of these courses.  Although some of this exposure to the large ABA literature presumably involves some unfiltered examination of individual studies, most is in the form of summaries of what the textbook or chapter authors believe the literature reveals.  This processing is obviously necessary, given the size and scope of the literature, and it provides valuable integration of information into practical guidance about how the technology can be effectively used to address a wide range of behavioral issues.

One can quibble about how well our textbooks do their job.  I believe they too often fall short, but that’s a tale for another time.  Aside from their quality, however, the availability of these materials begs some important questions about how well they are used.  How expert are instructors in the course subject matter?  How well do they select materials in developing course syllabi?  How high are their standards for student performance?  Let’s admit it – some educational experiences are simply superior to others.  This observation is supported by the recent release of BACB examination performance, which suggests that we have much to do to improve our ABA training programs.

And what are we training students to do?

The curricula and standards of our ABA training programs are their most obvious features, and they deserve scrutiny as our field continues to mature.  A more strategic issue may go unnoticed in this assessment.  What are instructors trying to do when they develop and teach ABA courses?  Aside from the many specific skills they would like to inculcate, what kind of professionals are they trying to create?  Not to be too grand, but the answer to this question may predict the future of our field.

In considering this overarching issue, we should appreciate that whatever its strengths and weaknesses, the ABA textbook literature does not force any particular instructional theme across training programs.  Even the BACB requirements for approved course sequences mandate only the minimum commonalities across programs.  Not surprisingly, programs vary widely in important ways.  Some focus on particular areas of service delivery, autism being the most obvious example.  In others, the predilections of program faculty may assure that their students receive special training in certain topics.  Organizational features such as the sequence of courses, the pace of program requirements, integration of coursework and field training, and on-campus and distance alternatives also give applicants a lot to consider.

Whatever the resulting combinations of program features, they produce newly minted BCBAs who bring a certain general style to their delivery of ABA services.  One such approach involves viewing clinical situations as occasions for applying rules gleaned from the ABA literature.  The rules may be more or less prescriptive across circumstances, but at its core this approach involves matching findings from ABA studies with the clinical circumstances under consideration.   This style of service delivery approximates a flow chart in which yes/no answers to a series of questions leads to the selection of specific behavior change procedures.  This optimistic tactic presumes an adequate literature underlying the behavioral issue at hand and looks toward the day when our understanding of clinical challenges will be sufficiently thorough to specify intervention procedures that guarantee effective outcomes.

A contrasting approach takes the same available literature as a starting point or background for a somewhat less rule-governed consideration of treatment possibilities.  It depends more on considering the literature as a whole – or at least its pertinent parts – as a basis for developing treatment options.  There is less searching for someone else’s prescription and more comfort in figuring out the details that suit each clinical situation.  Selection of intervention procedures is guided by not just relevant studies (if there are any), but by consideration of how current contingencies need to be changed to attain treatment goals.  In other words, this approach depends on the literature more as context for idiosyncratic selection of treatment components than as source for previously packaged treatment plans.

Using a recipe or cooking from scratch?

I don’t mean these descriptions to favor one approach over the other.  They are not in conflict, and both are useful.  They are only rough summaries of what are certainly overgeneralized differences in two styles of ABA practice.  In some cases, the match between clinical problem and technological solution is so obvious and the outcome so reliable that we just insert tab A into slot B.  In other cases, we start from scratch in considering how we’re going to get where we need to go – we just grab all our training and figure it out on our own on the basis of our understanding of the ABA literature, our experience, and our judgment as behavior analysts.  Of course, this bifurcation is overly simplistic, if only to pose the argument.  Actual clinical decision-making is certainly more complex than the present distinction implies.

We should look forward to the day that our understanding of particular kinds of behaving in particular circumstances is so thorough and our technology is so well developed that much of clinical practice is fairly routine and not all that creative.  On the other hand, we should not be timid about proceeding without this level of certainty.  We do know quite a lot about how behavior works and how to manage particular aspects of it, so the lack of well-established prescriptions for a certain problem need not be limiting.

Perhaps what we need to worry about is the proper balance between these two approaches in how we train students.  It would seem that ABA practitioners who routinely defer to one or the other are often at a disadvantage.  The ABA literature is just not adequate to consistently support a flow chart approach.  There is usually a less than perfect match between the details of a published experiment and each clinical case – if there is even a relevant study to examine.  It takes more than a study or two to provide good guidance about what procedural details will reliably assure what outcomes, and there are just not enough studies addressing the particular features that might be pertinent to each clinical case.  In addition, should we worry that those who need this level of guidance are not well prepared for circumstances in which it is not available?

On the other hand, practitioners who routinely approach each case without considering what the ABA literature offers that might be relevant, preferring to instead select procedures based primarily on their general knowledge of ABA techniques, miss the benefit of the literature that is available.  The field’s technology continues to grow more complex, and a seat-of-the-pants style – however sophisticated – will increasingly tend toward interventions that fail to capture the best procedural possibilities.  And if this approach dominated ABA practice, would the field gradually move away from its research foundation?

Just as practitioners need to be willing to look for guidance in the literature in making clinical decisions, they need to be confident about proceeding when such guidance is lacking or weak.  We need to prepare practitioners to keep up with the ABA literature and evaluate it critically and to be confident in their ability view each clinical challenge on its own terms and put together an intervention that uses the full range of their behavior analytic skills.  The balance of these clinical styles in any practitioner’s work should depend on the features of the presenting case and the suitability of the literature, rather than on whether the person’s training favored one approach over the other.

Teaching students to read, evaluate, and use the ABA literature is a relatively straightforward instructional agenda.  It is more difficult to teach them to approach their clinical work in a thoroughly behavior analytic style.  This way of approaching clinical problems calls on all that it takes to be an applied behavior analyst, including a solid understanding of operant learning, an expert command of the applied literature, competency in methods of measurement and evaluation, and knowing how to think about behavior devoid of mentalistic distractions.  With this foundation, students must be explicitly taught to reason through clinical problems, critically assess the value of any relevant literature, and proceed to develop interventions with cautious confidence.