After reading Fong, et al. (2016), Brodhead (2019), and Wright (2019) describe what steps you will take to ensure that

SPECIAL SECTION: DIVERSITY AND INCLUSION

Cultural Humility in the Practice of Applied Behavior Analysis

Patricia I. Wright1

# 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- evaluation and critique to address power imbalances and de- velop mutually beneficial and nonpaternalistic partnerships with communities (Tervalon & Murray-Garcia, 1998). Hook, Davis, Owen, Worthington, and Utsey (2013) described cul- tural humility as the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person]” (p. 2). Multiple social movements (e.g., Me Too, Black Lives Matter, Stand Up) are actively acknowledging inequity and encouraging discourse to address injustice for disenfranchised populations and marginalized communities. Research documenting implicit bias by health care providers toward marginalized communities and its deleterious effects has long been documented (Stone & Moskowitz, 2011; U.S. Department of Health and Human Services, 2017). Within the field of applied behavior analysis (ABA), there is inequity in who accesses effective behavioral interventions (Nguyen, Krakowia, Hansen, Hertz-Picciotto, & Ankustisiri, 2016) and in acknowledging that the design of behavioral interven- tions does not adequately address cultural differences (Fallon, O’Keefe, & Sugai, 2012).

The concept and process of cultural humility is meant to replace cultural competence, because the term competence denotes acquisition of knowledge of other cultures as an end goal that can be mastered, whereas cultural humility recog- nizes and requires an ongoing, lifelong learning trajectory (Freshman, 2016). Cultural humility training was originally developed to educate physicians to work more effectively with diverse populations (Tervalon & Murray-Garcia, 1998). Training in cultural humility has expanded to other profes- sional fields, including nursing (Fahlberg, Foronda, & Baptiste, 2016), social work (Fisher-Borne, Cain, & Martin, 2015), and education (Nomikoudis & Starr, 2016).

For the purposes of this article, the core elements of cultural humility in Fisher-Borne et al.’s (2015) model—individual accountability and institutional accountability—will be used as a framework for considering its application to ABA. This model assumes there are power imbalances that both individ- uals and institutions must work to address through ongoing learning and critical self-reflection. Although Fisher-Borne et al.’s model was developed for the field of social work, it is applicable to the work of applied behavior analysts. ABA, 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, 2018). Behavior analysts have individual responsibility as de- fined by the Professional and Ethical Compliance Code for Behavior Analysts (Behavior Analyst Certification Board, 2017), and both fields have established institutions that deliver

* Patricia I. Wright [email protected]

1 NEXT for AUTISM, 1430 Broadway, 8th floor, New York, NY 10018, USA

https://doi.org/10.1007/s40617-019-00343-8 Behavior Analysis in Practice (2019) 12:805–809

18 October 2019Published online:

social services, including nongovernment, government, and private agencies. Both professions have professional bodies guiding the science (e.g., the Association for Behavior Analysis International, the International Federation of Social Workers), practice (e.g., the Association for Professional Behavior Analysts, the Council on Social Work Education), and certification (e.g., the Behavior Analyst Certification Board, the National Association of Social Workers) within their fields. Applying the constructs of cultural humility to the practice of ABA may afford the field improved effective- ness and greater influence and promote equity in the distribu- tion of care.

The Application of Cultural Humility in ABA

Professional Ethics

The Behavior Analyst Certification Board’s (2017) Professional and Ethical Compliance Code for Behavior Analysts references both language and culture:

1.05 Professional and Scientific Relationships.

(b) When behavior analysts provide behavior-analytic services, they use language that is fully understandable to the recipient of those services while remaining concep- tually systematic with the profession of behavior analysis. They provide appropriate information prior to service de- livery about the nature of such services and appropriate information later about results and conclusions. (c) Where differences of age, gender, race, culture, eth- nicity, national origin, religion, sexual orientation, dis- ability, language, or socioeconomic status significantly affect behavior analysts’ work concerning particular indi- viduals or groups, behavior analysts obtain the training, experience, consultation, and/or supervision necessary to ensure the competence of their services, or they make appropriate referrals (p.5).

This acknowledgment of the importance of language and culture within the Professional and Ethical Compliance Code affirms the importance of culture at an institutional level to ensure professionals are working within their scope of practice. There are sparse data on the cultural diversity of behavior analysts. One paper recently conducted an in-depth analysis of gender (Nosik, Luke, & Carr, 2018), but other areas, including race, ethnicity, sexual orientation, and religion, have not been evaluated. Ongoing institutional and individual as- sessment of those practicing ABA can be conducted to further determine where disparities exist.

Ongoing Learning and Critical Self-Reflection Using Self-Management

The models of cultural competence and cultural humility are found outside of the field of behavior analysis; however, behavior analysts are beginning to voice the importance of cultural competence within their scope of practice. Fong, Catagnus, Brodhead, Quigley, and Field (2016) published an initial paper on the topic that was stated to serve as a starting point for developing behavior analysts’ cultural awareness skills. Beaulieu, Addington, and Almeida (2018) conducted 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- able and skilled in the delivery of culturally competent inter- vention. The majority of respondents felt moderately or ex- tremely comfortable and reported they were moderately or extremely skilled at working with individuals from diverse backgrounds. However, the majority of respondents also re- ported having little or no training in cultural competence. This reported confidence without training may be indicative of a need for behavior analysts to evaluate with greater scrutiny the application of cultural competence in their practice. One strat- egy to address cultural competence and humility within the practice of behavior analysis is to review how other profes- sional fields adopt culturally humble practices and assess the appropriateness of these practices for behavior analysis.

Fisher-Borne et al. (2015) provide a framework for the practice of cultural humility within the field of social work (Table 1). The questions posed within this framework are not operationally defined in a manner familiar to behavior analysts and require examination for use within the practice of behavior analysis. The well-established behavioral practice of self-management (Cooper, Heron, & Heward, 2007) might be considered equivalent to self-reflection and used to develop culturally humble practices. Self-management requires three steps: (a) a clear definition, (b) data collection and analysis, and (c) delivery of consequences. For example, a clear defini- tion may be that all clients have equal access to treatment, regardless of socioeconomic status, race, or ethnicity. Data are then collected regarding clients attempting to access inter- vention, and those data are assessed for bias. The data can measure the demographics of those attempting to access ser- vice against the demographics of the local community where the practice is located. If bias is identified, strategies are then developed to improve access and are then applied. If equity of treatment access is a goal for the organization, these data might be reported publicly during staff meetings and included in the annual report, resulting in positive reinforcement for meeting the goal and serving the community and in punish- ment by providing public visibility of not achieving a stated goal and perhaps the public perception of being

Behav Analysis Practice (2019) 12:805–809806

discriminatory. This is an example of self-reflection for insti- tutional accountability.

Self-reflection can also be used for individual accountabil- ity, including private events. For example, when prejudicial thoughts occur during treatment with clients, I will vocalize these thoughts to my supervisor during our supervision meet- ing and commit to assessing my bias and attempting to re- move that bias from my behavioral repertoire. Data can again be collected and analyzed on this individual behavior to assess for change and success or lack of success of the intervention. Individuals can record and report their frequency of prejudi- cial thoughts during their hours of practice. Positive reinforce- ment and punishment for this behavior can be provided through the social praise of a supervisor or through a written goal on a professional improvement plan. This is an example of self-reflection for individualized accountability.

Consider the following examples to further illustrate the application of self-reflection to promote cultural humility into the practice of ABA.

Case 1 A transdisciplinary team including a speech-language pathologist, educator, behavior analyst, and school psycholo- gist are collaborating to support a student exhibiting aggres- sive behavior toward others in the classroom. All members of the team agree that the student’s behavior is improving. The psychologist and educator have verbally stated that the

primary reason the child has had a reduction in aggression is the school’s commitment to trauma-informed care and that the educators are all now taking a trauma-informed approach in their interactions. The behavior analyst perceives that it is a result of functional communication training and systematic reinforcement. The behavior analyst is aware that collabora- tion in a transdisciplinary team can enhance the quality of services provided, but this behavior analyst has received lim- ited training on collaboration during preservice and in-service training (Kelly & Tincani, 2013). The behavior analyst shares with his supervisor that he does not understand the expertise and cultures of the other disciplines on the team and how they came to the conclusion regarding the child’s outcomes.

Applying self-reflection requires the behavior be defined; in this case, it might be a professional goal set with a supervisor of improving collaborative behaviors by identifying opportunities for cross-training with other disciplines (Donaldson, Stahmer, Nippold, & Camarata, 2014). The behavior analyst requests and attends training (preferably a competency-based training) in trauma-informed care to learn about the principles of the practice and better discern the perceived effect it is having on the challenging behavior. Data are collected on training atten- dance and competency outcomes, and the behavior analyst re- ceives reinforcement from his supervisor for attending a cross- discipline training. In addition, the behavior analyst, through attendance at the training, is now able to interpret the

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? • How do my cultural identities shape my world view? • How does my own background help or hinder my

connection to clients/communities? • What are my initial reactions to clients, specifically to

those that are culturally different than me? • How much do I value input from my clients? • How do I make space in my practice for clients to

name their own identities? • What do I learn about myself through listening to

clients who are different than me?

• What social and economic barriers affect a client’s ability to receive effective care?

• What specific experiences are my clients having that are related to oppression and/or large systemic issues?

• How do my practice behaviors actively challenge power imbalances and involve marginalized communities?

• How do I extend my responsibility beyond individual clients and advocate for changes in local, state and national policies and practices?

Institutional level • How do we organizationally define culture? Diversity?

• Does our organization’s culture encourage respectful, substantive discussions about difference, oppression and inclusion?

• How does our hiring process reflect a commitment to a diverse staff and leadership?

• Do we monitor hiring practices to ensure active recruitment, hiring and retention of diverse staff?

• Does our staff reflect the communities we serve? • Is our leadership reflective of the population/

communities we serve?

• How do we actively address inequalities both internally (i.e., policies and procedures) and externally (i.e., legislative advocacy)?

• How do we define and live out the core social work value of social justice?

• What are the organizational structures we have that encourage action to address inequalities?

• What training and professional development opportunities do we offer that address inequalities and encourage active self-reflection about power and privilege?

• 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

Behav Analysis Practice (2019) 12:805–809 807

nonbehavioral terms of trauma-informed care (e.g., promoting a safe environment) into behavioral practices (e.g., environ- mental arrangement as a setting event). An understanding of the behavioral principles of trauma-informed care to which the other team members are attributing the student’s success might 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- analytic training, as behavior-analytic language can be per- ceived as harsh or unpleasant (Critchfield et al., 2017). Refraining from reframing the practice in behavioral terms may increase the likelihood of positive interactions with other team members while collaborating on this case.

Case 2 A behavior analyst who was raised in a family of upper middle-class socioeconomic status and who currently makes a salary 400% above the poverty level for her geographic area of residence is providing parent training to a family whose financial status is below the poverty level. The training is to support the family’s engagement in generalizing activities of daily living into the home environment, including the promo- tion of independent eating and dressing. The behavior analyst shares with her supervisor that the family is not following the treatment plan by purchasing the items suggested for indepen- dent meal preparation, including microwavable prepared meals, nor have they purchased the suggested clothing, in- cluding elastic-waist, pull-up pants. She is concerned about the family’s lack of compliance with the suggestions and worries that they are not committed to participating in treatment.

Improving cultural humility through self-reflection is targeted as a professional improvement goal for this behavior analyst. The supervisor and behavior analyst define the behav- ior change for self-reflection; during supervision, the behavior analyst will vocally and in writing list the factors that may contribute to a family’s noncompliance with treatment goals. The baseline data are the initial lists created by the behavior analyst compared to the lists postsupervision, when the super- visor assists the behavior analyst through professional learn- ing to develop an understanding of the multiple cultural and financial barriers, including lack of understanding of socio- economic barriers, that would preclude a family from purchas- ing expensive food items and limit their ability to purchase new clothing. Positive reinforcement can be provided for in- creasing the frequency of items listed as barriers, for identify- ing alternative targets for treatment, and perhaps for sharing this learned experience with other behavior analysts as a peer educator. Negative consequences could result in required at- tendance at a professional learning event and increased super- vision when the behavior analyst is treating families with sig- nificantly different socioeconomic statuses than her own.

Establishing a cultural humility repertoire requires training and ongoing professional learning. The field of behavior

analysis is early in its application of culturally humble prac- tices to the field. We can take advantage of principles and strategies developed in other professional fields and tie our behavioral practices to their frameworks so that behavior an- alysts can improve their culturally humble practices.

Discussion

The field of ABA strives to achieve greater influence and improved outcomes in the application of the science. Disparity in the application of ABA exists. The application of cultural humility to the ongoing practice of ABA may me- diate this disparity and improve outcomes. There are limited data regarding cultural bias within the practice of behavior analysis. This article relies heavily on the practice of cultural humility exhibited by other professional disciplines. The cur- rent social movements calling for change are encouraging discourse within the field of behavior analysis. If ABA is going to expand its influence and ensure equal access, critical self-reflection and behavior change are necessary. Utilizing self-reflection may be a first step to analyzing both individual and institutional behaviors that are limiting the effectiveness of the application of ABA.

The field of behavior analysis is committed to using data to understand, motivate, and measure behavior change. Institutional data on the current cultural diversity of practi- tioners can be measured and reported regularly. This might include the voluntary and self-reported identities (e.g., gender, ethnicity, sexual orientation, socioeconomic status) of those acquiring certification in behavior analysis and those attend- ing events catered to behavior analysts (e.g., conferences, con- ventions, group continuing-education events), as well as at their career milestones (e.g., fellowships and board appoint- ments). These data could inform us of the characteristics of the current membership. An institution delivering behavior- analytic services can conduct a review of self-reported demo- graphics of its professionals and clients to determine if the institution sufficiently represents its local community. If there is disparity, implementing alternative recruitment processes can address the lack of diversity. Professional learning can be offered in cultural humility, and a supportive environment that affords opportunity for discourse regarding culture can be fostered. Behavior-analytic service organizations might also consider utilizing the National Standards for Culturally and Linguistically Appropriate Services (CLAS), developed by the U.S. Department of Health and Human Services’ Office of Minority Health, as an assessment tool to measure their institutional adoption of culturally humble practices (Koh, Garcia, & Alvarez, 2014).

This introduction to cultural humility is intended to be a starting point for applying the concepts to the practice of ABA with the use of self-reflection as an applied practice. A

Behav Analysis Practice (2019) 12:805–809808

behavior analyst can never become competent in knowledge and understanding of every culture. The field can begin by cultivating a culture of practice that accepts that cultural biases affect treatment. Individually behavior analysts have a respon- sibility to engage in self-reflection, assessing individual cul- tural biases and the consequent influences on their behavior and delivery of treatment. Given the uneven power dynamic inherent in the service delivery model, inspection and adjust- ments are necessary to ensure that optimal outcomes for the client are not inhibited by cultural bias. The development of culturally humble behavioral repertoires should be encour- aged in preservice and in-service training. Cultural humility is never mastered; it is an ongoing practice.

Funding The author received no specific funding for this work.

Compliance with Ethical Standards

Conflict of Interest The author declares she has no conflict of interest.

Ethical Approval This article does not contain any studies with human participants or animals performed by the author.

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