Acceptance and Commitment Training and the Scope of Practice of BCBAs

Thomas G. Szabo, PhD, BCBA-D and Jonathan Tarbox, PhD, BCBA-D

What is the future of applied behavior analysis? Will our field be useful in the next century in addressing matters pertaining to individuals other than those with autism and developmental disabilities? Will we devolve into another profession that makes use of mentalistic labels and practices? Will applied behavior analysis (ABA) be engulfed by the seemingly insatiable market for new brands of psychotherapy, much like social work, nursing, and other related disciplines?

A group of us are currently working on multiple fronts to address the ways that behavior analytic scope of practice can be nudged to meet the changing needs of our clientele and to address the problems faced by more diverse populations that we have a chance of helping without sacrificing the aims or the scientific rigor of ABA. We are tackling this mission through research, invited workshops, boot camps, keynote addresses at various conferences, and a variety of papers, including one specifically on scope of practice issues related to the ways that behavior analysis can benefit from and contribute to the psychological flexibility model encapsulated in Acceptance and Commitment Training (ACT). This work has been informed by and/or been done in collaboration with a variety of behavior analysts, including Emily Sandoz, Evelyn Gould, Steve Hayes, Mark Dixon, Daniel (“DJ”) Moran, Timothy Weil, Stewart Libman, Kendra Newsome, Joshua Pritchard, and Ruth Ann Rehfeldt, among others.

Incorporating ACT into mainstream ABA raises a range of topics that concern BCBAs. For example, is ACT a psychotherapy? If it is, would BCBAs using ACT be outside their scope of practice? This is an important question that deserves careful consideration. In fact, many disciplines with unique scopes of practice use ACT psychotherapy. And, many disciplines that do not use psychotherapy also use ACT! ACT is an approach to functional analysis and treatment of verbal behavior. This functional analysis can be effectively used to inform psychotherapy but ACT is not necessarily a psychotherapy, per se.

It might be useful to look at this matter diagrammatically (see Figure 1). The overlapping scopes of practice across multiple disciplines look a bit like a butterfly-shaped Venn diagram in which the psychological flexibility model is the body attached to which are different training and psychotherapy wings. For example, social work, clinical psychology, and nursing all make use of psychotherapy, but each have unique scopes of practice that only minimally overlap in this one area (note we are not claiming to be experts in any of these three disciplines). Coaching, safety consulting, and behavior analysis can similarly make use of  Acceptance and Commitment Training without crossing the border into psychotherapy. The phrase “psychological flexibility model” is an umbrella term that describes an approach that much larger than, but also includes, talk therapy. Within the overall psychological flexibility model is an approach that has frequently been described as “Acceptance and Commitment Training,” that is, ACT delivered in a modality that involves skills-based instruction, modeling, practice, and feedback. ACT as a training technology is no different from any other ABA technology in that its aim is to change socially relevant, observable and measurable behavior. The six repertoires taught in ACT can be taught as overt performances that when practiced regularly, increase the likelihood that a learner will engage in other difficult tasks. In this respect, ACT is not a substitute for, but an adjunct to other ABA technologies.

ACT is a functional analysis of complex verbal behavior consisting of verbal operants, stimulus equivalence, relational framing, and rule-governed behavior. Any time a behavior analyst talks to someone who has a verbal repertoire that is at least equal to a typically developing two or three-year-old child, the behavior analyst is dealing in derived relational responding and rules. Ergo, when is the functional analysis behind ACT within the scope of a  behavior analyst? In almost every single staff training, performance management, parent training, and behavioral consultation task we do every day. Put simply, we very rarely only directly manipulate the immediate antecedents and consequences of client behavior. Any other time, the verbal functional analysis and training interventions that comprise ACT are within our scope of practice.

Scope of competence is equally relevant to scope of practice. Just how much training does a BCBA need to perform ACT, training from whom, evaluated by what testing procedure, and administered by what governing body are questions that need to be addressed. Some suggest that additions to the current formal training sequence offered in graduate programs should be required. We are in agreement with this idea. Some additional coursework would be useful if ABA is to become relevant outside of classrooms, factory floors, and autism clinics. In addition, some additional basic training in interpersonal interactions, active listening, compassion, and empathy would be valuable, even if a behavior analyst never comes anywhere near psychotherapy.

Of similar concern are ways that BCBAs practicing ACT will measure the repertoires they teach, check their measurement for accuracy and bias, and assure that changes observed were the result of the treatment and not some other variable. Competence in these areas is critical to practicing as a behavior analyst, but that is true of every area of ABA specialization, whether it is early intervention skill acquisition, functional analysis and treatment of severe behavior, treatment of feeding disorders, consulting to fortune 500 companies, or applying ACT functional analyses and procedures to everyday ABA practice. Competence requires didactic coursework, rigorous training, mentorship, and supervision by someone else who is proficient.

Of concern to some is the apparent disconnect between radical behaviorism and the practical targets of ABA. Some within the ABA community seem concerned that ACT addresses private events and therefore is not behavior analytic or objective. Skinner’s philosophy of science, radical behaviorism, provided clear guidelines on this issue, starting in 1945. Private events are to be included in our science as both behavior (thinking, for example) and stimuli to which we respond (such as pain). Private behaviors are not causes of public behaviors; they are simply more behaviors to be understood. And like public behaviors, they can participate in complex behavior – environment interactions. Functionally, you can hear yourself think (covert verbal behavior that produces covert verbal stimuli) just as you can hear yourself say exactly the same words aloud (overt verbal behavior that produces overt auditory stimuli).

One concern commonly voiced is that private events cannot be measured with quantitative rigor. Of course, ensuring “True” measurement of private events is not possible, but private behaviors are not the dependent variable we measure in ACT work, nor are private stimuli the independent variables we manipulate. Private events are merely another part of the complex environments that we train our learners to respond to in adaptive ways. Large changes in socially meaningful overt behaviors are the dependent variables in ACT work and those are, of course, the stock and trade of all other ABA work, too. Likewise, to promote changes in overt behavior, our independent variables remain as they have always been: the MOs, SDs, rules, and SRs of which operant behavior is a function.

If that is the case, then why should BCBAs learn to use ACT? Our answer is that the verbal behavior that ACT addresses is important to the development of other repertoires. We might call the six repertoires targeted in ACT as pivotal behaviors that produce positive effects upon other performance classes. For example, learning to tolerate some discomfort is part of delay gratification, a broad skillset that we teach with a variety of different strategies that overpower the tendency to discount delays to reinforcement.

We notice a reluctance to talking about private events within the ABA community and suspect that this likely contributes to our science becoming trapped in a small pigeon hole (pun specifically intended) that is inconsistent with Skinner’s dream of a comprehensive science of all behavior. We argue that avoiding all reference to private events is akin to playing the short game in golf. As a strategy aimed at keeping the precision of ABA high, this has been fruitful. But we suggest that our field now has the tools with which to play the long game. Moreover, we suggest that problems faced by our traditional clients as well as those faced by populations we might aim to help in years to come require us to play a bigger game. That game is, as it always has been, to save the world with behavior analysis and it requires we address private events within the seven dimensions of ABA.

Many behavior analysts rightly have concerns over turf wars that may emerge between disciplines as behavior analysts adopt ACT more widely. Our position is that we cannot afford litigious battles with other disciplines and can avoid them with careful planning. Perhaps the clearest line of fracture between behavior analysts and licensed psychologists is that behavior analysts do not do psychotherapy, unless they are also licensed clinicians and acting as such. In disseminating ACT and adopting it into mainstream ABA, we need not challenge this distinction. When behavior analysts use words to change behavior, we do so as a means of training, coaching, and performance management. We manipulate SDs, MOs, SRs, and rules, and only for the purpose of bringing about socially meaningful overt behavior change. If this is psychotherapy, then we can never train parents, train staff, manage staff performance, or attend an IEP meeting again. Of course, much more work needs to be done to clearly delineate Acceptance and Commitment Therapy (outside of ABA) from Acceptance and Commitment Training (inside of ABA), but using words to change behavior cannot possibly equal psychotherapy, or else all who are not licensed psychologists would need to simply shut up.

We cannot expect to be relevant in the future unless we begin to carefully, respectfully, move our practice forward. Science is progressive; so is science-informed practice. We have more tools now than we did in 1968. We need to vet new tools and use them only with proper training and oversight. We have not as a profession agreed yet what that training, oversight, and testing will look like. Let’s have that conversation. Let’s create, carefully, and with an eye on the prize, new ways to help others and move our profession forward.