Operant Innovations 008 | Issues of Multicultural Diversity in the Ethical Practice of Applied Behavior Analysis | Part 2

Shauna Costello (00:01):

You're listening to operant innovations, a podcast brought to you by ABA technologies today. Today we are continuing our series on multicultural diversity. If you missed part one, feel free to go back and listen at any time today, we'll hear from Dr. Kim Killu.

Dr. Angela Cappellano (00:20):

So now I'm going to turn the presentation over to my colleague, Dr. Kim Kallu, and she's going to talk about the cultural differences and interpersonal boundaries.

Dr. Kim Kallu (00:31):

Thank you. Hello everybody. Yes. I'm going to talk about the cultural differences in interpersonal boundaries and that's something pretty significant in our practice of applied behavior analysis. And I'd like to present to you a case profile of something that I actually found online in social media. I think social media is a great way for behavior analysts to communicate with one another and learn from one another. And so that's where this case comes from, and I've modified it just a little bit to ensure some confidentiality, but I'm going to read the case to you and then discuss this case in the context of the ethical issues that surround it. So the case starts out as follows.

Dr. Kim Kallu (01:20):

I have been working with a client for one year. I was just informed that due to religious reasons, I am not ever supposed to touch my client and she is never supposed to touch me because we are of the opposite sex. Her programming currently involves the use of physical prompting, which I had to cease immediately. My client is also an affectionate person. She loves giving hugs, shaking hands, et cetera. I have suggested that a female take over her case and my agency has arranged for this. However, the client still sees me on a daily basis. She becomes upset when I do not allow her to physically interact with me, which is pretty much turned into me, not allowing her to interact with me in any way. Furthermore, she apparently is not supposed to be interacting with any other males, whether it be peers, teachers, or therapists, these circumstances have presented quite the dilemma.

Dr. Kim Kallu (02:17):

And I'm angry that my employer and the BCBA never informed me of this religious barrier. And I had to find out from angry parents because they saw their child attempt to hug me a hug that I had actually redirected to a more appropriate handshake. Obviously I want to respect the family's religious beliefs, but that this client still sees me every day is an issue. That I am no longer able to interact with her is causing her extreme duress and extreme behavioral concerns. All my supervisor had to say to me that it was a quote unquote, a tough situation. You can see there's really some significant issues that this behavior analyst has deal with his client. It's important to remember that interpersonal touch is really a critical part of human social communication. We engage in touch with one another quite often, whether it's on a more mild form or more intimate form, and it's very much a part of how we all interact with one another.

Dr. Kim Kallu (03:21):

There's actually an area of study called haptic communication. And that examines the way that people communicate via touch. Physical contact varies across culture with social distance greeting engagement during conversation and public versus private settings. In the degree of physical contact can vary by one's ethnicity, and culture, gender to gender interaction, age, the kind of relationship that people have areas of the body that are touched the context of touch and the degree of emotional closeness between the parties involved, typically across cultures, the stronger the emotional bond, the more allowances for touching are granted. In some cultures, we might see strong pats on the back and firm and painful handshakes are used to greet strangers. In other cultures, touching someone's head, including touching the head of children is seen as incredibly offensive. Whereas in other cultures, it's seen as a sign of affection. In some cultures, two men holding hands is a sign of brotherhood and friendship.

Dr. Kim Kallu (04:31):

Whereas in other culture, similar behavior suggest romance. So physical touch between those of the opposite sex is seen as unacceptable in some cultures. So we really have to examine the nature of practices across cultures in the families that we're working with. So what I'd like to do is go through some of the elements within our code to discuss how these issues in the code have implications for our practice. Code 1.04 talks about integrity and how behavior analysts are truthful and honest. So we arrange the environment to facilitate this. The BCBA here should really work with the family. To be honest with them, honest with the parents, honest with the client, the circumstances here have put the BCBA in a pretty awkward position. Rapport is already been established presumably between the family and the BCBA, but it seems definitely so between the BCBA and the client and the client is making progress.

Dr. Kim Kallu (05:37):

So we need to ask ourselves, how did this go on for a year? And I realize I'm presenting something that I got off of social media, but it makes you wonder how this wasn't communicated or how nobody really found out that this was going on for a year of treatment. We need to find out our client's preferences but we can't necessarily accommodate a situation where no males are present. That would be pretty difficult for any agency to carry out. These are the types of questions that need to really be asked at intake before somebody comes in and before treatment is developed and before treatment is actually carried out, if a clinic can't accommodate a family, then the clinic really needs to be upfront in helping the family to find a service provider who can accommodate them. Code 1.05 talks about professional and scientific relationships.

Dr. Kim Kallu (06:35):

The code talks about language that is fully understandable, that we provide appropriate information prior to service delivery. That behavior analysts have obtained training, experience, consultation, and supervision necessary to ensure they're competent to provide the services. And that we don't knowingly engage in behavior that is harassing or demeaning to people with whom we interact. The treatment teams should meet with the parents and clients to discuss this matter and the best way to proceed. It's important to remember that in some families and in some cultures meeting with an extended family may also be necessary. I recall a meeting that I had once with a family and before I knew it, 30 people were walking in the door and all 30 people had to agree to what we were proposing. So that's in some cultures, that's normal behavior, typical behavior, and we need to be accommodating for that.

Dr. Kim Kallu (07:34):

The team should be frank in that they didn't anticipate this issue happening with the client. It would be very difficult for all of us to be savvy for every single culture that we encountered. And I think it's important to be able to be upfront and to let people know that I'm sorry, I wasn't expecting this. I wasn't aware of this necessity. And let's work to change this and let's fix it for you. The people providing the services and the agency should work to be more culturally competent to meet the needs of their families and their clients. We can seek out this contact from our own clients to ensure social validity. It's okay to talk to our families and our clients about their cultural needs in their cultural requirements. And we should be honest and expressing our own cultural incompetence. We are all culturally incompetent to some degree.

Dr. Kim Kallu (08:29):

And we want to ensure, ensure to the family that the mistakes that we made in navigating through their culture. We're certainly not intentional. We're learning too. And that's okay to admit that by continuing to ignore the situation, the treatment team is in fact, demeaning the client and family, our frame of issue. Isn't the issue here, the frame of reference of the client and the family are the issue. So we need to be respectful of that. Once we're aware of any type of mistake that we make, I suggest that we acknowledge it own it. Yes, I did this. I made a mistake. I'm sorry. We want to apologize and talk with the parents and the clients to make sure that it doesn't happen again and brainstorm ways to move forward. Code 2.09 talks about treatment intervention and efficacy. And it talks about how we review and appraise the effects of any of our treatment.

Dr. Kim Kallu (09:24):

Though there may be no measurable effects on the target behavior of having a male versus a female therapist here. The matter is really one of social validity, social validity can have longterm implications for treatment efficacy. So we want to make sure that we're aware of that. Ucode 2.15 talks about interrupting or discontinuing services. The code talks about how we act in the best interest of the client and we avoid interruption or disruption of services. We facilitate the continuation of our services. We discontinue services only after efforts to transition have been made. And we're aware of the harm that may come to clients by discontinuing services. And we don't abandon clients. Uit was appropriate for the treatment team to discontinue the use of the male therapist in transition to a female therapist. However, a better option may have been to immediately suspend treatment and meet with the parents and clients to discuss the matter.

Dr. Kim Kallu (10:29):

There may be more to this issue than face value, meaning having a male versus a female therapist, it's imperative to have a thorough and frank discussion about the matter. Simply switching to a female therapist may serve as a bandaid. It's much like doing a functional analysis. We want to get to the root of the problem. So we want to make sure that it's just not the issue of the male versus female. As the team transitions to a female therapist, additional supports may be necessary to ensure the client's progress. There may be some regression with the transition. The development of old behaviors or new behaviors may emerge. Rapport is going to have to be established with the new female therapist. So again, because of all of these issues, some supports may be necessary to put in place. But we have to recognize that culturally and religiously the client is being harmed by the continued treatment with the male therapist.

Dr. Kim Kallu (11:29):

Though that might not make sense to us. 3.01 in the code talks about assessing behavior. It talks about conducting current assessments and the assessments are determined by the client's needs, et cetera. A thorough assessment upon intake that evaluates cultural norms, needs, expectations, et cetera, would have avoided this matter. This should really become standard practice for behavior analysts. We do a great job of assessing our target behaviors and developing programs, but we don't do such a great job of evaluating the norms and needs of expectations of our family and our clients. I think that we should work to improve this. As a field, we should be more aware and sensitive to these kinds of issues. We like to say that we're sensitive to other cultures as behavior analysts. And I think people are well intentioned when they say that, but we tend to be very American centric in our views and interventions.

Dr. Kim Kallu (12:32):

And we tend to force our perceptions on, of appropriate behavior and necessary skills onto the client and the family. Just as an example, in US culture, we highly value independence, doing things on your own, but in other cultures, independence is not valued. Interdependence may be a strong value being part of a group and contributing to the overall welfare of the group is what's important. So by working to facilitate some of the treatment plans that we do that look toward working on more independent functioning, we may actually be offending some of the clients and families that we work with. Code 4.06 talks about describing conditions for behavior change program success. And it's important for us to describe to the client, the environmental conditions that are necessary for a behavior change program to be effective at intake, during assessment and before, during, and after the development of our treatment plans, including before intervention elements of the program should be reviewed with the family and the client.

Dr. Kim Kallu (13:47):

So answers to questions like who, what, when, where, why, and how should be answered, and we need to be specific. So I think it would be important for families to know that we may have more than one RBT, for example, coming in for treatment. And they may be males and females. We need to let them know exactly the nature of treatment. If it's going to require somebody to actually physically touch the client for hand over hand intervention, we need to be really specific about things like that. 5.0 talks about the behavior analyst as supervisor and that supervisors take on full responsibility for all aspects of treatment. I find the supervisor's response to this matter to be highly negligent and grossly inappropriate. If the supervisor does not know the best way to assist the supervisee in addressing this matter. And let me say that would be okay that the supervisor doesn't know how to address this because all supervisors don't know how to address every single issue that comes up.

Dr. Kim Kallu (14:56):

But if the supervisor doesn't know what to do in this case, he or she is obligated to seek out resources and supports for helping the supervisee to address the matter. In 10.06 talks about being familiar with the code, and we're obligated to be familiar with the code familiarity with the code serves to help therapists avoid similar situations. I think it's really important to look at case studies and go through case studies in the context of the code, because that helps us to learn more and help to generalize the code to different situations. Again, with being familiar with the code, I think the supervisor is particularly negligent here. Some considerations with this with this particular case, you know, it's, it's really easy for me or anybody else to sit here and look at that case that I found off of the internet, off of social media and look at it in retrospect and say, well, this treatment team should have done you know ABC and XYZ to avoid or address cultural infractions.

Dr. Kim Kallu (16:03):

Again, it's really easy to do that. And that's not the point of pulling up that case to say, look, they should have done this and that. Again, it's to learn from a case and to see how we can adapt our behaviors to best meet the needs of clients while learning from the experiences of other people. But we encounter ethical situations with every single client. We have an every single plan we develop, even, even with people who look just like you, because culture is not solely about race and ethnicity, personal values, personal preferences, personal history, individual repertoires, boundaries, reinforcement histories, and comfort zones make up our own personal culture. And that personal culture is separate from our racial and ethnic identities. When we look at culture, it can expand into several subcultures. Those subcultures can be things like age, language, or dialect that you speak, socioeconomic status, social class, educational level, religious beliefs, geography, and location, gender, sexual orientation, gender identity, relationship, status, disability, political beliefs, and one's own familial practices.

Dr. Kim Kallu (17:28):

So think about yourself and how you might check off the box on all those different, all those different variables that I just mentioned. Think about your clients, think about their families. You can check off different boxes for all of them. The contingencies associated with each of these subcultures dictate our own behavior, the behavior of our families and the expected behavior of our clients. So some final thoughts with this is behavior analysts really little time assessing the cultural contingencies of our clients without an examination of one's cultural practices, meaning the values, the preferences, desires, et cetera, our interventions and targeted outcomes can lack social validity. Applied behavior analysis continues to hold Western centric values and pursues Western centric, target behaviors. We have to remember that common data collection strategies used by behavior analyst may not address the cultural preferences and norms of our clients.

Dr. Kim Kallu (18:37):

The selection of the target behaviors that we use for our clients are really an expression of values and treatment plan goals are valued decisions. Are these goals are values or are they the values of our clients? Something to think about. And when we have issues like lack of follow through that might suggest that the intervention that we've developed may not be culturally appropriate. And we really need to consider that our own interests and experiences are not necessarily the norm and our own failure to look beyond ourselves has implications for our growth, the growth of our clients and the perception and longevity of our field.

Shauna Costello (19:20):

Thank you for listening to operant innovations. Come back on Friday to hear the concluding part by Dr. Danielle DeLong and a Q & A with all three of the presenters. And as always, if you have questions, comments, feedback, or suggestions, please feel free to reach out at operantinnovations@abatechnologies.com.