Operant Innovations 007 | Issues of Multicultural Diversity in the Ethical Practice of Applied Behavior Analysis | Part 1

Shauna Costello (00:00):

You're listening to operant innovations, a podcast brought to you by ABA technologies. This week, we start our new series on multicultural diversity and applied behavior analysis. I had the pleasure of seeing this presentation at a conference earlier this year, and I invited them to speak on the podcast. So this is going to be a three-part series. And today we're going to hear from Dr. Angela Cappellano.

Dr. Angela Cappellano (00:28):

Today, I will be talking about applying multicultural issues to the work of a behavior analyst. We're going to be looking at how this works through some different kind of focused problem areas and how we should look at and take a multicultural lens when we are addressing the work that we do with our clients. It just to `sort of ground us and get us started. I think it's good to look back at what Skinner had said.

Dr. Angela Cappellano (00:59):

And Skinner addresses the idea of culture of course, many times, but he really talks about it and addresses it in his book beyond freedom and dignity. Basically culture is, you know, according to Skinner a collection of behaviors they are learned and they are passed down within certain groups of people and behaviors that are reinforced are the ones that survive and become part of the culture. So we can keep that in mind as we go through and look at how this can represent in different ways for the clients that we work with. Now, if we look at the field of ABA and how we are looking at culture and how we are addressing it we actually find that there's actually seems to be a lot lacking in our research literature. There's not actually a whole lot of research to go off of here.

Dr. Angela Cappellano (01:54):

So when I was looking into the existing research literature, there's some things that emerged. It is interesting that one survey of currently practicing BCBAs found that most of these BCBAs feel that diversity is important and those BCBAs feel like they are competent in treating multicultural clients. Although they do also indicate that they have received little formal training on multicultural diversity. And many people have noted that there is a lot more need for education on multi diversal multicultural diversity practices and ABA. And we know with our, you know 5th edition task lists, there still is no requirement to have any kind of formal classes in multicultural issues or diversity needs. I also, a recent literature review that looked into the ABA literature. They look specifically at studies of language acquisition and just did a large analysis of the currently existing literature on ABA practices and language acquisition.

Dr. Angela Cappellano (03:08):

And from studying the currently published studies, they found that there is actually most of the studies did not even list the participants cultural backgrounds or the languages that they spoke. So, you know, in ABA, we're all about our data well we can't even analyze data, if we don't have the data to begin with. So it's in research studies authors are not even listing the cultural backgrounds of the clients that they're doing research with. We really don't have anything to analyze. We have no basis of knowing really what, what is research supported and what works with different groups that we may work with. We're going to go through a specific area. So I'm focusing on one particular area. And so I kind of created this client scenario based off of some different clients that I've worked with and other people that I know that have worked with these particular issues.

Dr. Angela Cappellano (04:01):

So I'm going to introduce a client, the client and I'm, this, this course is a made up name, but the client's named Irav. And he is a 19 year old Indian American male. He's been diagnosed with intellectual disability and autism spectrum disorder. Now his family requested the help of a BCBA specifically to help with his toileting behaviors because he does not use the toilet. He wears pull-ups and, you know, pull ups for an adults have to be special order. It is becoming quite an expense for the family and they would like to transfer him to being more independent with the toilets. So they do not have to constantly purchase pull-ups and then participate in his toileting behaviors. And he has this kind of unusual behavior when he currently has to go to the bathroom and he lays flat on his back and he kind of shakes his limbs until he goes in his pull-up.

Dr. Angela Cappellano (04:57):

And so his family would like for him to be able to use the toilet and be a little bit more independent with his needs. Now, if I was just going to proceed like normal, I would say, all right, now BCBA toilet training. I got this right. I'm going to get my task analysis. I'm going to get my data sheets. I'm going to figure out like when he needs to go, what schedule his body is on, and then I know how to use the toilet, boom, let's go with it. And if I were to proceed as normal, I might be missing out on some really important considerations that I should be taking for this client. And so if we look at toileting, toileting is actually a very cultural kind of practice. Even if you just look at it mechanically, like the behaviors that we go through in toileting, the facilities that we use, the tools that we use, and that can vary incredibly by the culture that you live in and where you live in the world.

Dr. Angela Cappellano (05:58):

So like in the United States we have a lot of assumptions about toileting. You know, we expect a flushing toilet, we like clean facilities. We want to have toilet paper. And I think right now we can all appreciate how valuable toilet paper is to us, right. When it's the first thing to disappear from the stores, clearly we all value it. And we also like a lot of privacy, too, right. You know, we expect to go into a public restroom and have it be a private stall that has a door that closes completely. We want to have our privacy. And then we also expect to be able to immediately wash our hands right afterward. I know that I get really irritated when I'm in a public restroom that only has cold water to wash my hands. You know, not only do I want to be able to wash my hands, I want to be able to use hot water.

Dr. Angela Cappellano (06:45):

I want to use soap. I want everything to be very clean and hygienic because that's important, in my culture and that's, you know, the kind of behaviors that were reinforced when I was learning toileting behaviors. But if we look at different areas around the world, toilets can look incredibly different depending on where you are. And if you want to feel really out of your element when you're traveling to a different country just go and use a public restroom. And then I think you will realize you are in a very, very different place from what you are used to. Then I think it becomes kind of clear to you what your, what your assumptions are about a lot of things. So like in some cultures, like in some Eastern Asian countries, like I have some pictures here of bathrooms in China, where if you were to look at them, they I think they'd be referred to a squat toilets.

Dr. Angela Cappellano (07:38):

So the first thing that you might notice is that there's nothing to sit on. There's no seat. You are expected to be able to, you know, balance and, and hold yourself up and just squat over a hole. And then you can also see a lot of places do not have enclosed stalls either. There may be walls that close people off from each other, but they tend to be very short because if you're squatting, they don't need to be as tall as you are. And there's not a door in front, so there's actually very little privacy. Another thing that some people might notice too, is that there is no toilet paper and a lot of parts of the world. They don't use toilet paper to clean themselves after toileting. So there's a lot of things that you might not know what to do.

Dr. Angela Cappellano (08:21):

I mean, if I were to walk into this restroom right now, I would really be at a loss. Cause I would be thinking, okay, I get the point that you have to squat. There's nothing to sit on. But then I would wonder about like, how does that work with your clothes? You know, what do you remove? How undressed do you get? Do you take off your shoes? Do you put them back on? I don't know. I would be very, very confused if I had to use this kind of toilet. So I realized that I am not being really competent in using such a toilet. And these can vary really greatly depending on where you go now. In Europe, it's really common to have a bidet right next to your toilet. So you may have your toilet and then you may or may not use toilet paper and you may have a bidet that's right next to it.

Dr. Angela Cappellano (09:02):

Some places are actually getting really high tech with their toilets. I know I went into a sushi restaurant in Denver once and it was just this tiny little restaurant, but I went to the restroom. I was kind of amazed at how high tech the toilet was. It had all these electronic things attached to it. You could choose like the color of the light that lights up the inside of the bowl of the toilets, because I don't know why that's important, but you could, you could choose that you could also choose like the temperature of the toilet seats. And I'm sure there were other options, but I was honestly to confuse to use any of the fancy options. But in other places too, you know, toileting is not such a private behavior. I remember when I was a student doing a study abroad program and I walked out of the train station in Amsterdam.

Dr. Angela Cappellano (09:52):

And like immediately, once you exit the train station, just on the street, there are public urinals and there are these stall looking devices, but they're not closed. They're open on all sides and it's just like a little corner that a man can go into and use that to relieve himself. Right, right on the street, just right out there in the open. So that was pretty shocking to me. And then, you know, in some parts of the world too, like in Europe, it's actually very common to be charged, to use a public toilet. And I remember using one of these when I was in Europe as a student. And I remember I, we encountered some automated ones. So you would walk out into the street and it was like this machine, you would put your coins in the slot and then this door would open for only a few seconds, just long enough for you to go in there and then you could use the facilities and then exits and that's kinda normal in Europe, but I know that idea that we have to pay to relieve ourselves.

Dr. Angela Cappellano (10:54):

Is like so offensive to Americans that was actually the basis of an off Broadway musical called Urinetown. The whole sort of premise of Urinetown was that the homeless people in New York city had to pay to pee on the street. And apparently hilarity ensues. I don't know, I did not see it. My parents did. And they said it was a riot. And now people are, I think kind of like a, sorta like a new wave of toileting. A lot of people are trying to discuss maybe the most anatomically correct position that one should be in when they eliminate. So that has led to the sort of viral sensation of the Squatty potty. And I've said this before, but if you ever find yourself with a few minutes to kill anyone need to amuse yourself, look up YouTube and look up the original commercial for the Squatty potty.

Dr. Angela Cappellano (11:44):

It's hilarious, but you can see there's so many different behaviors that are reinforced depending on, you know, where you live and what facilities are available to you. So if I were to just go back to this client and try to train him in the behaviors that I am familiar with, I might be missing the picture for him. I might not be giving him the most socially valid behaviors that his own particular culture and home environment would support and reinforce. So we have to keep that in mind, right? Toileting behaviors are really not universal. They're not, they vary incredibly really depending on where you live. And there's many issues that are really brought up with toileting. You know, it's not really just the act of toileting itself. It can really bring about different parts of somebody's culture that are really praised and reinforced, right?

Dr. Angela Cappellano (12:37):

It brings about notions of privacy. What, how much privacy do you expect? You know, how much privacy do you need in order to feel comfortable? And again, this varies greatly, you know, in the United States, we like a lot of privacy and our behaviors. But in other places you know, public restrooms are not quite so private. It also brings into notion, you know, the ideas of hygiene versus purity, right? In the US, we really like things to be hygienic, right? We worry about germs and bacteria and contamination, right? We want toilet paper, it's disposable. We flush it. We wash our hands immediately. Those things are very important to us. But in other cultures is not so much hygiene as is this idea of purity, like how morally clean or dirty are you. Right. And that brings up other issues too. Right?

Dr. Angela Cappellano (13:24):

So in some places how you clean yourself is extremely important. Whether you use your right hand to clean yourself or your left hand, right. If I was just going to approach a client here in the United States, I would say, let's use the dominant hand. That's what I normally go for. Because the United States, it doesn't make so much of a difference. However, in many cultures which hand you use to clean yourself is incredibly relevant. And using one hand will be highly reinforced by your natural environment and using the other hand will not. In many places the left hand is the hand that does all the dirty work. And regardless of what hand is your dominant hand, you must be trained to clean yourself with your left hand. Should we also think about males versus females too? There are very different behaviors that can be promoted and reinforced for how males eliminate and clean themselves and how females do that too.

Dr. Angela Cappellano (14:19):

Right. And we also think about too, how do we learn all of these things? Well, we learn these things from the people that we live with, the people that surround us. So we have to look at who a client is living with and what their natural environment is supporting and reinforcing in order for us to construct the behavior plan that is going to be most socially valid for them. So we take this back to Irav, the client that I had been assigned to work with. I wanted to do some more investigating into maybe what toileting practices maybe his family would be most familiar with. And in many places in India they American style of toileting is not quite so common. So you're more likely to encounter those squat toilets, where there's not something to sit on.

Dr. Angela Cappellano (15:10):

It's a whole, it's not, I mean, it's a little more advanced than a hole in the ground, right? There's a hole that is covered with some kind of metal. And there's, you know, a specific drain where all of your waste and everything goes, but typically you're also not going to find toilet paper. Very commonly people will clean themselves with either on a hose attachment or a bucket or a cup of water where one can, you know, rinse themselves with the water and use their hand to clean themselves and then wash their hands really well afterwards. So if I was approaching Irav, assuming that he's going to have a toilet to sit on and toilet paper I, again, I might not be equipped to help him complete this issue in a way that his natural environment is going to support.

Dr. Angela Cappellano (15:54):

So I need to think a little bit broader though, too. So now maybe I have a better understanding of the toileting practices and behaviors that his family is accustomed to. But as I have to think about is, you know, what is Irav's, natural environment and this is going to be broader for him than his family. So for many individuals, we have to think about well there might be one set of practices that their family is used to, but we also have to think about you know, of course during normal times where is the client spending majority of their time. If this was a school age child, I would have to really consider, you know, with the facilities that the child is using at school and making sure that they have the behaviors that are competent to use the facilities, that they would be encountering in a public space for this particular client though because he was older and he was not attending school.

Dr. Angela Cappellano (16:44):

He was mostly at home with his family. So that was the primary place where he was spending his time. So it did make sense to train him in the toileting behaviors that his family used and promoted because he was not encountering public toilets very much. However, like I said, if this is a younger child, there's somebody who is expected to spend a lot of time outside of the home, I would have to really carefully consider what set of behaviors make the most sense for this client to learn and what natural environment are they exposed to to make sure that I am being sensitive, but also training them in the behaviors that are going to be needed for the tasks that they need to do. So then I have to think about too well, how does this family toilet, right? I might have a general idea of looking up stuff online, but I need to really understand this better in order to create a good and comprehensive and really socially valid plan for him.

Dr. Angela Cappellano (17:41):

I have to think about, you know, these ideas of social validity and also the generalization of this behavior change too. So what is most socially valid for Irav`? You know, what, what behaviors are needed by the environments that he is exposed to and what is important for him individually. And then also think about too, how can this how can these behaviors translate across environments? If I train him in just what his family is doing, what's going to happen if he's exposed to, you know, a toilet that is different from the one that he uses at home. So he may need to be trained in multiple different kinds of behaviors to make this behavior change really generalizable across multiple environments. And so I think whenever we're presented with a professional challenge, we want to look to the professional and ethical compliance code for guidance and making sure that we're addressing the relevant issues.

Dr. Angela Cappellano (18:30):

So I've gone through, and I picked out the parts of the code that I think are most relevant. So this is not an exhaustive list, but these are the ones that I think are most relevant to Irav's situation. So of course we can only work with clients within the boundaries of our competence, you know, which is determined by our education training and supervised experience. But we have to think about here, how, how can we be competent? You know, if we've already determined that there's really not enough training and ABA, in multicultural and diversity issues, we have no formal training on it. And I know for myself, I never encountered a supervisor who had multicultural training and toileting practices. How can I know that I'm competent, right? If I can't even go into the research literature and find the information that I'm looking for to find, you know, what does the research literature say about what is the most supportive practice?

Dr. Angela Cappellano (19:22):

I can't even find that information. How can I even know what competence in this issue in this even looks like? So of course, well, when we're not competent, we get supervised training. Okay. That sounds great in theory, but what if you can't find, what, what if you can't find that, you know, in Michigan and Ohio, I don't know that I can find a supervisor who's a BCBA who is experienced in all of these different kinds of toileting practices. So I may not be able to find this by the traditional routes. Of course we don't discriminate against our clients. Right. And I think that obviously there's a lot of behaviors that fall underneath that that are pretty obvious and people say, yeah, yeah, I know I can't discriminate against my clients, but I think we have to really think about this on a deeper level and think about, you know, what, what we are bringing to the situation, you know, behavior analysts, we are not totally neutral objective observers.

Dr. Angela Cappellano (20:16):

We're not, you know, we come with our own personal histories our own personal problems, conflicts, you know, behaviors that we believe should be promoted and reinforced. And we bring that to the situation that we have with our clients. So I think we have to be very aware of where we come from and what behaviors are promoted and reinforced in our own backgrounds and cultures, and really figuring out how that can maybe conflict with some of the clients that we have. We want to make sure that we respect the behaviors and practices of our clients. And honestly I have to think it's going to happen to most behavior analysts. The more people you work with, eventually you're going to come across a client that may have some values and promote some behaviors that may conflict with your own. And that can be a very tricky sort of issue for us to proceed with.

Dr. Angela Cappellano (21:10):

But I think it's very important first that we become aware of what our own backgrounds are and what behaviors are promoted and reinforced in those backgrounds. When we are starting to, you know, judge some of the practices of our clients, and honestly, and we'll talk about this more, but I mean, we really have to confront and recognize that creating a behavior plan for our clients mean it is, it is a judgment, it is a judgment of, you know, what behaviors are most appropriate. You know, we are determining often what are appropriate, inappropriate behaviors. And a lot of that is based on our own personal beliefs as well. You know, when you may accept clients, we can only accept clients that we are experienced and competent to treat. But again, what if you're thrown in a situation where you, you don't even know what a competent practice is you can't find a supervisor who has ever worked with this client before, right?

Dr. Angela Cappellano (22:02):

I mean, I don't think we should just say, Oh, I can't do it. Sorry, good luck. Keep searching. You know, I think we have to really challenge ourselves to try to become competent for our clients, um as best we can while making sure that we are going back to the code, looking at the research letter literature and checking in with supervisors or colleagues to determine if we are proceeding in the right way. And of course they can remember our clients, you know, they do have a right to effective treatment. So again, I don't think we should just sort of throw up our hands and say, Nope, can't work with you. I don't know how to do this. You know, perhaps we should take that as a challenge to figure out what might be the most effective treatment for that client. Right. Very carefully taking data, analyzing that, checking that, making sure that we are making progress for our clients.

Dr. Angela Cappellano (22:48):

And so that we can help people that maybe have issues that, you know, have not been commonly encountered. In this particular case for Irav, I would want to have a medical consultation. I would want to rule out any kind of competing medical issue because there may be a reason that he has these unusual toileting practices. I would just want to make sure before I proceeded behaviorally that there was nothing medically going on especially with his gastrointestinal system. For him, I would definitely recommend doing that first. And then also just remember to the individualized component of our behavior change programs, right? We need to create a behavior change program that is beneficial for our clients. So it's not just determining, you know, teaching them in behaviors that we think are appropriate, but what behaviors will their own natural environments support and promote.

Dr. Angela Cappellano (23:38):

And that's where the individualized component really comes out. So if I were just to, you know, address this toileting practice, the way I always lived with everybody without really digging into this client's background and maybe what the family's practices are, I might be really missing out on some important things for that client. And I might not be able to create a really good behavior plan for him. So, you know, I'm proceeding, right? I want to have a good task analysis because I realize I am not competent myself to create a task analysis just by, you know, my own behaviors. In this case, it's a private behaviors. This would not be very appropriate for me to observe and create a task analysis. So I think in this case, how I would proceed is I would ask the family to help develop a task analysis as they are going through, you know, their typical toileting procedure.

Dr. Angela Cappellano (24:28):

I would ask them if they can keep a notepad or something and jot down the steps that they are doing as they're doing it. So that would give me a basis on something to start with. And then they could even help assess the client to determine what steps they can do on their own. And you know, if I had a supervisor, I would definitely check in with that supervisor, although I know a lot of BCBAs are out there practicing independently on their own. So I think this also kind of brings up the issue. You really gotta have a good supportive network of colleagues that you can seek out help with to, you know, I think peer supervision is great where we are checking in with each other and bouncing ideas off of each other. You know, working in isolation is not usually a good thing for any of us. So, you know, developing that good supportive network of colleagues is going to be helpful too. And then really considered to what environments your client is exposed to and what behaviors are supported and promoted in those different environments. I think that will help you as you proceed in a situation that might be similar to this.

Shauna Costello (25:27):

Thank you for listening to this episode of operating innovations. Please make sure to tune in on Wednesday and Friday for the remaining two sections of this presentation. If you have questions, comments, or feedback, please feel free to email us at operantinnovations@abatechnologies.com.