28 Thursday May 2020
Now that the annual conference for ABAInternational is past (whew!), Cusp Emergence is excited about upcoming webinars and online conferences (New Hampshire and FABA, I’m looking at you!). First up is a partnership with Connections-Behavior.com: We will look at trauma-informed behavior analysis in two parts, on June 1 and 15. Register here for this CEU opportunity!
24 Tuesday Mar 2020
Tags
behavior analysis, camille parsons, coronavirus, Covid-19, ethics, mane, pandemic, reporting child abuse, telehealth
This is the 19th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. Start by becoming informed; then please read to the end if you’re interested in taking steps with your organization to support therapists and teachers to continue to fulfill their roles as mandatory reporters.
Child abuse, elder abuse, domestic violence, and abuse of people with intellectual disabilities is going on all around you. It may have just become simultaneously more prevalent, invisible, and insidious.
For example, in some areas, there has been a marked decrease in calls to the hotlines that typically lead to welfare checks for vulnerable people in their homes to insure that families have resources they need, children are not being abused or neglected, and appropriate actions can be taken if they are. (See this story from Colorado reporting a drop in calls the 9th and 10th of March as schools began to close).
Across the nation, different states are reporting similar decreases in calls but also a spike in the number of serious child abuse hospitalizations and even deaths.
Reasons for this disturbing increase are numerous. Little annoyances become big ones when there is no possibility of a break and both mental health (e.g., patience) and physical (e.g., food and sleep) resources are running thin. Even a normal battle on whether your kid will eat the peanut butter sandwich becomes a crisis when you’re trying to feed several people a balanced diet with whatever dwindling foodstuff you still have in the cabinet, while money (and outside trips) become scarce.
For many families, the struggle is not only real but getting uglier by the day, by each hour the kids are home from school.
There is conflicting advice, some of it really unhelpful, yet most of it well-intentioned. (I read a recent article about how we should just give in and let kids watch endless videos during this unprecedented time; but for many children, a huge increase in access to media may be accompanied by major behavior challenges (and even injurious and aggressive behavior) when parents try to have them turn it off for meals or bed. Research shows increased screen time can cause impulsivity, hyperactivity, and inattentiveness,
all of which are even more difficult to deal with when you’re cooped up. Of course, you need solutions, and the quick fix is even more appealing right now.
And there are major barriers to resources. Some have said this crisis is leveling the playing field, but really, it’s revealing discrepancies.
Being quarantined at home doesn’t hurt that much when there’s plenty of food, you already know how to navigate technology to work from a home office, and there is room and time to get away from housemates or family members for a little while.
Being at home with other people who normally require 7 to 9 hours of behavior support and school-provided structure, let alone meals, while you work to make ends meet—that is another story altogether.
So there are the struggles to which we can all relate, and then there is the reality of jumping into these struggles with no help, no end in sight: There is the reality of suddenly not being able to be by oneself for even a minute, and not knowing when it will end; there are children whining or crying (or hurting themselves while other things need their caregiver’s attention; there is behavior, so much behavior, that a parent doesn’t know how to handle and is made worse by a lack of structure, suddenly upended routines, and for some, the complete loss of safety figures. At the same time, there are abusive people who are now alone with their victims for the next few weeks.
Maintaining a safe environment for a child depends on several behavioral and environmental factors. Right now, those factors are not all present. Instead, we have
-Caregiver behaviors that are really important to keep people safe, but may not be FLUENT (such as giving effective instructions to a child, creating a schedule for several people, or responding to unsafe behavior that you usually don’t have to respond to)
-Caregivers that may physically present, but not AVAILABLE (e.g., an adult who can provide continuous, adequate supervision to every single member of the household who needs it)
-The presence of new circumstances creating unsafe environments (such as having 3 children with special needs home at the same time, for hours and days on end, and without the things (therapies, bus drivers, respite workers, social outings and educational time) that typically provide structure and relief)
-The additional presence of huge stressors (the unending flow of news about the virus; the dwindling of food and resources; the loss of jobs)
-Competing, sometimes incompatible, needs (like people home from work who need quiet to make money but who also have to provide constant caregiving and supervision; or people who have intellectual and other disabilities and are without their scheduled programs, events, therapies, social opportunities)
-Therapists and teachers who are working from home or not at all, but who normally document and relay evidence that a child or adult may be being abused, mistreated or neglected
These factors and more combine to produce
-The occasion for more abuse or neglect to occur
-Decreased opportunities for abuse to be reported
-Emotional and physical needs that may make the outcomes of a child being quiet or following directions suddenly much more important or reinforcing, whatever the cost
So, my therapist, day program provider, and educational staff friends- how will you add and document safety checks for all your clients on a reliable schedule to take the place of “having eyes on” the client in your clinic, their home, or your school or program?
There are no hard and fast answers. For instance, some behavior analysts are out of work; could they be repurposed to providing online support of families with children at home? Having eyes on the family is good, but it’s also introducing a risk that we will give advice that we don’t have an assessment to back up, or that is not fully safe to implement. And while I’d like to share ideas for behavior analysts to incorporate safety checks of your clients virtually, it’s most important for me to encourage you to reach out, right now, to your organization—and ask for your TEAM’S plan to do that. This is because different states and areas have different guidelines and requirements for you to follow depending on your local recommendations for HOW you monitor and report unsafe situations. You need to do it, but you should follow your local guidelines and state laws.
Telehealth provision is already a new skillset for some employees, including teachers, and if they are suddenly without any social support when they used to be able to walk down the hall to the counselor, administrator or psychologist on site, they may freeze and wait when action is important. It’s your job to make the unfamiliar but correct action as easy and supported as possible.
And here’s a notice: Social services haven’t closed down. In Colorado, not only are they still making visits, they are hiring. Hotlines are available and staffed with trained professionals to take your call.
Resources: Read guidance from the Behavior Analysis Certification Board on ethics, safety and more related to Covid-19.
Here’s more on how a few states are monitoring this issue.
Colorado:
Call 1-844-CO-4-KIDS if you suspect abuse or neglect
For birth to 3 receiving services: http://coloradoofficeofearlychildhood.force.com/eicolorado/EI_QuickLinks?p=Home&s=EI-CO-Response-to-COVID-19&lang=en
And in Texas, use this info:
https://www.allianceforchildren.org/
If you suspect a child is being abused or neglected, please contact the Texas Department of Family and Protective Services toll free at 1-800-252-5400, 24 hours a day, 7 days a week.
You may also file a report using the secure TDFPS website. Reports made through this website take up to 24 hours to process.
The Texas Abuse Hotline is 1-800-252-5400.
18 Monday Nov 2019
Behavior Analysis, Aging, Trauma, and Supervision (or BATS, in honor of Dr. Janet Ellis).
This is the 18th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. It includes something new that we have been asked about: Companion notes for students and supervisees working through this information with the support of their supervisor.
I heard Jon Baker give a great talk on advances in behavioral treatment of gerontology the other day at COABA. It made me think of my students at the University of Colorado Denver and our supervisees. (There was also a fantastic talk on supervision and feedback by the incomparable Ellie Kazemi, whose book on supervision is out now). When they ask about clients other than autism who have benefited from applied behavior analysis, my supervisees are usually excited to read stories in which ABA changed the lives of people with dementia, brain injury, medical needs, and more. For example, an article from Baker (2006) Continue reading
03 Monday Jun 2019
“Trauma-informed behavior analysis”: Redundant term or useful phrase?
This is the 16th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.
Trauma-informed behavior analysis, abbreviated TIBA, is a phrase I’ve been using for a few years now to describe what I do to people outside behavior analysis. I do this because it helps them to understand how I apply the science, and not to suggest that “regular” behavior analysis should not address trauma. From those behavior analysts who have not been to my trainings, I often hear the question “Isn’t it redundant to describe behavior analysis as trauma-informed?” I would argue that the short answer to this question is “yes”. However, this article describes why the more important and longer answer is “yes—and it’s still useful”.
About this outline: As one of our current projects at Cusp Emergence, Dr. Camille Kolu is aggregating several years of data (including feedback from existing BCBAs, educators, foster parents, and social workers) in writing a set of articles on the topic of applying the science of behavior analysis to behavior change after a person has experienced significant trauma. This topic comes up frequently on behavior analytic forums. Please note that this brief outline does not describe the SAFE-T model (by which we advocate appropriate supervision, functional assessment, risk documentation, and environmental modification and training) or solutions to all the challenges it raises. Check out the other blogs on this topic, email us if you’d like to provide comments and questions, or see cuspemergenceuniversity.com for CEU and training opportunities.
Background: How is “trauma-informed behavior analysis” redundant?
I. The ethical practice of behavior analysis already requires it.
II. The application of behavior analysis already covers it (see Baer, Wolf and Risley 1968, 1987)
III. The underlying science of behavior analysis and work on learning and behavior already describes phenomena related to behavior after trauma (see literature on reinstatement, contextual conditioning, respondent behavior, extinction in multiple contexts, etc)
The current state: How is the phrase “trauma-informed behavior analysis” still useful (even needed) if it’s technically redundant?
I. I believe it’s helpful to both practitioners and client base.
II. This phrase also gives me a way in, to talk to groups who haven’t had good experiences with behavior analysis
Dreaming of the future
My goals include that one day in the near future,
Takeaway: I agree that saying behavior analysis should be “trauma-informed” can be redundant, since the basic science is rigorous enough to describe why our behavior is changed after and challenged by trauma. But I use it because it helps communicate what I do to people who have a specific history, and to help other behavior analysts understand how to establish an ethical approach to the intense documentation, risk mitigation, collaboration, and assessment that is required while using existing behavior analytic procedures to support those affected.
What’s your take? Send me a note or share a resource any time.
See or add to our growing reference list related to behavioral treatment of trauma.
29 Tuesday Jan 2019
Tags
beauty and the bug, beauty and the bug cusp emergence, ceu bacb, cusp emergence, ethics ceu, trauma, trauma and behavior analysis, trauma and developmental disability, trauma and ID, trauma-informed behavior analysis
Beauty and the Bug (in which we briefly explore trauma and non-neurotypical people, ask how to raise tender-hearted children, and see a bug portrait in pointillism)
This is the 15th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.
How do we teach others to tend the needs of those who cannot express them (or for that matter, appreciate the lesson of loss, the tenderness of pain, the beauty in brokenness)? And how common is trauma in individuals with serious developmental disabilities? Many of us have not considered the relevance, let alone the prevalence. Is this because we can’t see it, don’t hear about it, or think that it is out of our scope to address? These questions occurred to me this week as I thought about a participant from a recent training I provided, who asked if the model of trauma-informed behavior analysis (about which I’ve been writing here) applied to individuals with intellectual differences (it does!). Even to us professionals in the field of behavior analysis, the complexity of and subtlety of trauma and behavior remains elusive.
This week my family lost a wonderful man. He and his wife tended to the needs of others (often before their own). Also this week, my reason for taking a work break turned three months old, and Imagine! (a nonprofit agency in my area) had its annual celebration. As I mulled over these questions about trauma and differences and on raising good people, a therapist friend posted Imagine’s video of one of their clients. I realized I had not blogged before specifically about treating challenging behavior in someone who is differently abled. I need to do that, lest one more reader think that this approach (trauma informed behavior analysis) is mainly useful for “vocal” clients, or those who can easily articulate their pain and past. Today, Shelly and her zany personality inspired me to do this.
Individuals with developmental and intellectual differences express or show their history and needs in different ways, and sometimes caregivers overlook the contributions and signs of trauma, neglect or even ongoing abuse. When we (especially behavior analysts) overlook these, we are not addressing the real reasons for challenging behavior, and we might miss the importance of connecting the person with critical mental health resources, or of offering a chance to heal past wounds. We know about functional communication training. But do we fully address subtle needs to communicate pain—both emotional and physical? And when someone lives in an environment or is exposed repeatedly to a situation or person that is aversive (even abusive!) do we teach them to effectively advocate for removal and communicate their discomfort, or do we merely try to reduce the “challenging behavior” that often accompanies the terrible situation? Do we recognize the signs of abuse in individuals who have few skills to communicate?
Too many times, I took a case where team members requested decreases in “challenging behaviors” in someone with diseases like Parkinson’s, Alzheimer, or Spina Bifida, before the team had recognized that the main thing challenging about the behavior was that it was going on because the individual had NO dignified way out. A conversation with a peer last week revealed that without training in these issues, a behavior therapist or even the entire team might treat “suicidal ideation” as a “behavior to be decreased” rather than a serious problem to be solved. (Even when this “behavior” is partly a habit the person has learned to use as a tool to produce needed attention from others, a whole behavior analysis of the situation would consider the risks and possible outcomes of addressing it in different ways, and document and address the related needs to understand and address why this was happening.)
As Shelly and her team alluded to in the video, the very state of not being able to communicate one’s needs and preferences can be traumatic in itself, and can lead one to develop desperate behaviors that just get called “behaviors for reduction” in the individualized behavior plans of thousands of clients. Today there are no more excuses for not helping someone access and master a communication system that works for them. To be sure, not everyone has access to a Smart Home residence decked out with all the tools we saw on the video- but have you seen the article on an accessible app developed by the brother of a man with autism in Turkey (so that he could communicate needs and gain leisure skills using only his smartphone)?
Tragically, many of my clients went through abuse and neglect and need someone to write careful and informed behavior plans that teach them skills they did not have at the time, like articulating emotional and physical pain, advocating for their needs, and requesting to be removed from a serious adverse situation. Just as important, these clients need an informed analyst who designs ways that these skills will persist when the client moves environments, as I found when a former client kept being exposed to new team after new team that didn’t read the plan and failed to recognize the communicative intent of the behaviors, and the medical component to the “challenges” the team demanded to be decreased. This calls for TIBA or trauma informed behavior analysis (if the team is not already using it).
So it’s not enough for our clients to learn these skills one time. The people who make up the audience, the environment, must respond enough to maintain them. If I ask for help and you respond no, why would I ask again? Remember the lessons of the family whose school team actually discouraged them from using “saying no” as a goal for their adolescent girl with autism, arguing that they didn’t have the resources to deal with her protesting all day long. Actually, the opposite is more likely to be true—that when our “no” is respected (listened to the first time), its use will be more limited to situations in which the person really “needs” it.
So back to my original questions. How do we raise little ones who are likely to grow up to appreciate and shape the voice of the voiceless, who honor the needs of people in ugly situations, who see the beauty in what others view as broken or beyond repair? How do we insure people will have the internal resources to value what isn’t immediately perceived as “valuable” by the culture? Maybe it starts when they are little, in modeling ways we can accord dignity to the frail, the elderly, the dirty. We cultivate tenderness as we show them we appreciate the spiderweb (AND the spider), the weed and its flower, the worm (thanks, mom and dad, Nicolette Sowder of wilderchild, and my very first client who taught me that not being able to talk is not the same as not having anything to say- click here to learn about Rett Syndrome).
Thanks to mom and dad, I still notice bugs and their beauty. I thought this one was wonderful when I looked closely, so I spent even more time to study and draw him. I thought he became even more beautiful as I continued to look. Maybe you can see his beauty too.
Colorado Potato Beetle by Camille Kolu (c) 2018
P.S. There is so much trauma in our schools today, whether you work with students who are “typically developing/ neurotypical” or those with intellectual, developmental and physical differences. Don’t miss the next course from Cusp Emergence University on trauma informed behavior analysis in the educational setting (complete with CEU’s including one for ethics).
Some references and resources
Articles on prevalence of assault and ACES in individuals with developmental differences:
https://injuryprevention.bmj.com/content/14/2/87.short
http://www.cfp.ca/content/52/11/1410.short
Read about Imagine! Smart Homes: https://imaginecolorado.org/services/imagine-smarthomes
Read about the man who developed an app for his brother: https://www.bbc.com/news/av/stories-47001068/how-brotherly-love-led-to-an-app-to-help-thousands-of-autistic-children
Get the full TIBA (trauma informed behavior analysis series): https://cuspemergence.com/tiba-series/
19 Friday Oct 2018
Tags
collaboration, community, partners, self-advocates, trauma, trauma-informed behavior analysis, visual tools
This post is part of the series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, Ph.D., BCBA-D.
Sometimes you meet someone who does work that you can really get behind. Over the past month, I have enjoyed learning about Awake Labs, a Canadian company providing easy and elegant solutions to self-advocates, families and teams who need to track information, data, and progress in the context of clients’ stories and strengths. Their Reveal Stories are an interesting way to do this. Awake Labs partners with community educators, providers, and medical professionals, offering ways to collect data and graph progress. During our conversations this month, Paul Fijal of Awake Labs also interviewed me about my work with trauma and behavior analysis, posting our interview on their blog. Check it out!
17 Tuesday Jul 2018
Posted in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, boundaries of competence, collaboration, Community, Education, ethics, resources, risk analysis, risk assessment, risk versus benefit analysis, supervision, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized
Tags
ethics, risk assessment, risk management, risk versus benefit, risk versus benefit analysis, trauma, trauma-informed behavior analysis
This post is part of a series on trauma-informed behavior analysis by Dr. Camille Kolu, Ph.D., BCBA-D.
When treating behavior concerns after trauma, we may find that clients exhibit risks to themselves, risks to their community, and risks to caregivers that should be documented. Why have behavior analysts sometimes turned a blind eye to documenting these risks? Read on to discover some common reasons I found in the field, and ways we can address them.
When it’s too risky to even consider the risks
Our field has adopted a Compliance Code which mentions the need to document risks. As an instructor for courses in a BACB-approved course behavior analysis course sequence, I use a textbook that provides sample templates for documenting and analyzing risks. And as a practitioner, I have found that my analysis or assessment of risk is almost always helpful to a case (as in some situations I’ll describe below), not to mention that it’s quick and simple it is to do.
Despite these facts, most behavior analysts I encounter do not analyze risks in any sort of written format. The behavior analysts around me range from BCBA-Ds to RBTs, and many have expertise and long careers. Why are we averse to documenting risks?
I have been researching the answer to this question for several years, and often the answer is “because I don’t have a good risk assessment”. So I made some and piloted them with different agencies, working through the problems of how to identify, define, document and mitigate the risks related to the populations with whom I work most closely. But at a recent training opportunity I received a different kind of answer, and I think it’s too important to keep to myself.
Some of the BCBA’s I talked to at that event were not documenting risks, they acknowledged, because it was just too risky.
At first it seemed counterintuitive. If I was providing a new document that made it easy to document several options, and the potential risks and benefits of each, wasn’t that inherently reducing the risk? No, it turns out. To many of us, highlighting a risk necessarily imposes some degree of liability.
We’ve faced this challenge before. In pointing out a problem we may become partially responsible for solving it, as some educators have learned the hard way when their schools are upset with them for discussing the observations of a student’s difficulties outside of the official process. This responsibility may carry a financial burden or create an unsolvable problem in a resource-poor area. And some pediatricians I know have mentioned the frustrating dilemma of being given a new depression screen for teens or moms, only to have nowhere to go with the results.
A new ethical responsibility is only as useful as your agency’s process to fulfill that responsibility, and procedures to support the people implementing the new responsibilities.
And in the discussion with the BCBA’s that day about risk documentation, I learned something really interesting. The specific language I used made a huge difference in their willingness of adopting a new procedure.
When I called it a “risk assessment”, BCBA’s were unwilling to adopt my new “assessment”, even if it was backed up by the compliance code and plenty of evidence and anecdotes how it has supported my work.
But when I called it a “risk versus benefit analysis”, they were willing to try.
The difference?
“Risk assessment” is a loaded term that carries legal weight in many contexts.
On the contrary, the other term (“risk versus benefit analysis”) is something that I use daily, and that is simply a process of documenting and analyzing the several different options available, together with their respective potential risks and benefits. It’s called for by the Compliance Code (and discussed by Bailey and Burch in their Ethics text).
According to the Compliance Code, “a risk-benefit analysis is a deliberate evaluation of the potential risks (e.g., limitations, side effects, costs) and benefits (e.g., treatment outcomes, efficiency, savings) associated with a given intervention. A risk-benefit analysis should conclude with a course of action associated with greater benefits than risks.”
The Compliance Code mentions risks in several places. In 2.04b, we are to consider risks of performing conflicting roles (e.g., when we are clarifying third party involvement in services). In 2.09c we are asked to use a risk-benefit analysis as part of our process in deciding between different treatments. And in 4.05, we are asked to work with stakeholders to present the potential risks versus benefits of which procedures we plan to use to implement program objectives. 7.02 asks us to consider risks involved, when there may have been an ethical or legal violation by a peer. And of course, we consider the potential risks and benefits when doing research (9.02).
The Task List does not mention “risk” by name, but alludes to the process when requiring that we are required to be able to state and plan for the possible unwanted effects of reinforcement (C-01), punishment (C-02), or extinction (C-03), as well as behavioral contrast (E-07). Similarly, the Code makes it clear that we are to identify potential for harm with using reinforcement (4.10) and identify obstacles to implementing recommended treatment (4.07).
In my practice, the most efficient way to meet all these objectives and more, is to complete a risk-benefit analysis. I love to include sections on mitigating the risks I do identify, so that the team can make an informed decision about what resources, training, information or support they will need to implement the least risky option.
And a final benefit I’ve heard many stakeholders mention during this process (and typically I do the analysis as an open discussion in which they are involved and brainstorming), is usually stated like this: “I didn’t think we had any other options, but when we approached this with a goal to identify alternatives and the risks and benefits of each, we uncovered several more”.
The risk versus benefit analysis is something I document, add to a treatment plan or employee or client file or IEP, or simply something I share with the team in writing and in person to solidify systems support for my next move. Recently, the following situations were ameliorated by using a transparent risk versus benefit analysis. Outcomes included increasing appropriate funding; securing appropriate medications; identifying appropriate caregivers; funding appropriate training; and improving client satisfaction.
-what kind of residential facility would be most appropriate to move a client to
-whether to discharge a client now or later
-whether to use a cheaper program with fewer resources or a costly one with many
-whether to put a client in a foster home in a potentially risky but supportive situation
-whether to delay an assessment to have an operation
-under what conditions should we discontinue a client who violates our informal no-show policy
-what caregiver to select from several available
-how to appropriately include police contact in a plan in a way that reduced long term risks
-what medication to decrease and when
-whether to put a student in a restrictive school with more behavior support, or a less restrictive placement with more social interaction options
As you can see by the last two, sometimes these decisions are not cut and dry. They depend on the team and family input, and one family may weigh a given outcome more heavily than another. Everyone has a history. To do these analyses in a compassionate and open way is important, and sometimes we don’t agree. To involve high level stakeholders and funders is critical as well.
What are the risks of doing a risk-benefit analysis? Perhaps you’ll highlight more risks than you thought were there; perhaps you’ll have to take some responsibility for the outcome of your recommendations. But what are the risks of avoiding this important process? If you are certified, your responsibility as a behavior analyst “is to all parties affected by behavior-analytic services” (e.g., 2.02). So are there risks of not documenting risks? Sure. You could cause harm or be negligent if there is a known risk you didn’t plan for or discuss with the team. Just like there are risks, there are benefits too. Doing a good risk versus benefit analysis is certainly a helpful cusp for supervisors and behavior analysis leaders to acquire! Many times we have uncovered risks that can be totally avoided next time if we were to act now to change or solidify policies, or use preventative measures in the future. A risk-benefit analysis can be a wonderful contribution to discussing lessons learned.
There are more options to be uncovered. Go out there and find and document them!
Want a resource? Check out the 3rd edition of the Bailey and Burch text Ethics for Behavior Analysts (2016), read more on Cusp Emergence , or check out a risk versus benefit tool (I like to do this on a whiteboard with my teams).
Convinced? Have a question? Drop us an email. And thanks for reading about this important topic. We’d love to see how YOU document and discuss risks!
21 Monday May 2018
Tags
acceptance and commitment therapy, ACT, behavior analysis, mental health, mental health month, trauma-informed behavior analysis
(Part 14 of a series of posts about Trauma-informed behavior analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)
Connections between mental health and behavior analysis 
This topic is always close to my heart as I work regularly in mental institutions, and as my business supports wellness practices that affect everyone—including those of us who need help prioritizing our own mental health. But it’s an especially important topic right now: May is Mental Health Month!
Sometimes my work involves conducting an assessment to see whether a client needs behavior analysis, or mental health support, including ways to thrive with a history that includes mental illness. In other words, sometimes (many times!) directly providing mental health support goes beyond my scope, and my job in those cases involves referring to other providers or more typically, collaborating with them. But instead of those cases, today we discuss some intersections between behavior analysis and mental health. If you’re board certified or licensed you’ll want to keep a copy of your field’s ethics code handy (here’s mine, as a BCBA-D). If you’re a family or team member wondering about these connections, read on.
No matter your certification, it’s never ethical to work completely out of one’s boundaries of competence. However, it’s also true that applied behavior analysis has supported individuals with mental illness concerns (including those with symptoms of challenges such as schizophrenia) since the field’s very beginnings. Young BCBAs without historical education in the full range of our field’s applications might have been surprised to see the transformation on some 1950’s psych wards of a population with various psychiatric disorders as patients changed from non-social and despondent individuals to interacting with their peers and their behavior analysts. They met goals they set for starting to take care of themselves again as they got dressed, talked more with peers, worked, visited families, and traded in tokens they earned for individual items they wanted to earn, such as a radio to keep in their room. In the earliest days of applied behavior analysis, Ogden Lindsley and colleagues used reinforcement schedules and behavioral apparatus to analyze psychotic behavior and to reveal that it was subject to operant mechanisms just like other behavior. Behavioral treatment of schizophrenia, in that area, became robust, effective, and almost commonplace. For example, Kurt Salzinger analyzed the verbal behavior of persons with schizophrenia and showed that it was related to discriminative stimuli and consequences of people around the patients (Salzinger and Pisoni, 1958, 1961). A later literature review of articles between 1959 and 1972 (Stahl and Leitenberg, 1976) showed that across 23 articles describing programs for psychotic and chronic mental patients, the individualized behavior programs were widely and substantially effective, producing large improvements in the behaviors that were targeted. History students might enjoy Stephen Wong’s “Behavior Analysis of Psychotic Disorders: Scientific dead end or casualty of the mental health political economy?” (Wong, 2006).
But don’t forget the important caution I mentioned while beginning this section: Without training and expertise and supervision in a given population, any work, no matter your field’s history, is still out of one’s scope. Even so, for those behavior analysts with a more limited history, there are still the vast literatures on the empowering use of self-management to change addictive behavior, manage anxiety, self-monitor triggering situations and select and strengthen one’s own coping skills. These are widely used and well researched. In fact, before there was ACT (or Acceptance and Commitment Therapy), there was self-management. (For a good introductory text on behavioral self management see Alexandra Logue’s Self Control: Waiting Until Tomorrow for What You Want Today). Wherever social contingencies matter, behavior analysis can generally help.
Although using behavior analysis in mental institutions generally fell out of favor decades ago, it has been markedly effective in my last few years of work helping others with mental illness learn skills needed to transition to meaningful lives outside the institution, sometimes after decades in those facilities (or years in group homes, foster homes, and inpatient units). Here, the behavior analytic skills of systems support and functional assessment have been useful for teaching teams how to support individuals who had nearly given up on finding a more permanent home.
Collaboration with providers
What someone needs most and first is sometimes collaboration and support, not an intensive 1:1 ABA session. For my clients with mental illness or mental health needs, it has been extremely helpful to:
-get the entire team on the same page
-look at what has been going wrong (e.g., review incident reports and challenges that have repeatedly plagued the attempts to help the person)
-discover what the team wants
-find out what has been a recurring problem? What is keeping the client from the life they want? Who cares about the client and what skills are missing?
-establish communication protocols for the team
-find out what behavioral and other strategies were already in place and whether or how they are working (Often, a team has been using a token system, or behavior plans, or consequences, or attempts to change behavior using antecedents or instructions and modifying motivation, before a behavior analyst ever entered the picture. Our job is to document what has been done and how this has worked; along the way we can often help an entire agency understand how to make their routine interventions more ethical and effective.)
When I have gathered all of that information plus interviewed team members and my client, documented my review of reports, other supports, and the contributions of medical, historical and childhood factors and the client’s and team goals, I have the makings of a behavior assessment and am able to begin sharing recommendations with the team. These recommendations may include more appropriate and consistent strategies, additional documentation of risks to the client and their community, and training on treatments and ways of interacting that may be more effective and helpful to the team and client than what has been attempted in the past.
Stop for a minute: does all of this suggest that a client is necessarily out of a behavior analyst’s scope of service because they struggle with mental illness? No; furthermore, nothing suggested here discounts the important roles of mental health counselors, psychiatric nurses, social workers, psychiatrists and psychologists, and the other members of the treatment team. If anything, my past several years of work has taught me that a good collaboration has usually resulted in making their roles work even better.
Another way behavior analysis is involved in mental health is the important need to protect our own mental health.
In our line of work, we must be able to respond compassionately and calmly to burned-out staff or clients whose behavior “targets” us, perhaps physically, emotionally, or all of the ways a staff person can be targeted or hurt in the line of work. A recent and excellent training on ACT for intellectual disability shared studies in which it helped reduce staff burnout and increase engagement with clients. These two are related, for when I am healthy and calm I can respond more appropriately and consistently to my clients. Since my clients are often staff, it also helps when I train them in techniques that will help them maintain consistency and calm when they are confronted with the daily grind of their own jobs.
One of the simplest yet most effective interventions is arranging an enriched environment—it grows neurons, increases social behavior, and supports virtually every population. Although it can take less time than waiting and intervening in crises, it is not something an inpatient staff can or wants to do when burned out.
When I teach staff how to stay calm and respond calmly and with preventative input (e.g., my preventative schedule or NCR approach), this is often a burnout-protective approach. It IS behavior analytic, but it’s not complicated.
Connections no one planned
Mental health and ABA are also connected accidentally, when a mental health therapist learns their client is receiving ABA, or a behavior analyst learns their client has also been diagnosed (e.g., anxiety, bipolar disorder, PTSD, or others). In these moments we are forced to look at the connection: what do we do to support the client? Ethically, perhaps we should reach out to learn how the family feels about collaboration; maybe the psychiatric team would love to hear how we are supporting behavior change at home or school and how the data change when medications are changed; or maybe there are important risks to document, or helpful suggestions to make that would help the team stay on the same page. Yet often one or more parties says “not my role!” and makes no efforts to implement connected support. Notice again this is still not suggesting to go outside your role, but to work more collaboratively with others as much as it is appropriate (e.g., Ethics Code 2.03a-b).
Taking care of myself
Finally, here are some other simple behavior analytic strategies that help me manage and protect my own mental health so I stay focused and available to bring my best self to client interaction.
Manage my schedules of reinforcement
I carve out time for myself daily- I make time for tea, breakfast and stretching- all important preventative appetitive things I need to approach regularly.
Set up and honor stimulus control strategies to decrease my exposure to stressors
-Take off email notifications on my phone: Sure, you don’t have to answer them, but how many times has one subject line told you about an upcoming stressor, increased your heart rate, or interrupted your use of coping skills or important family time?
-Limit checking email to when you are prepared to respond (not necessarily by hitting reply, but read it and respond by writing a note you’ll save and send later, perhaps). (If scrolling through my account before bed I notice an inflammatory email, I can pause and return tomorrow. I recently practiced this—stopped reading past the subject line until the morning, and first meditated and had breakfast. It was still upsetting but I found that I was able to answer it and move along).
How do you think behavior analysis and mental health are connected? We love to hear your input, stories or questions.
Selected references and resources
Anthony Biglan, Georgia L. Layton, Laura Backen Jones, Martin Hankins and Julie C. Rusby, The Value of Workshops on Psychological Flexibility for Early Childhood Special Education Staff, Topics in Early Childhood Special Education, 32, 4, (196), (2013).
Lindsley, O. R. (1960). Characteristics of the behavior of chronic psychotics as revealed by free operant conditioning methods. Diseases of the Nervous System (Monograph Supplement), 21, 66-78.
Lindsley, O. R., & Skinner, B. F. (1954). A method for the experimental analysis of the behavior of psychotic patients. American Psychologist, 9, 419-420.
Salzinger, K., & Pisoni, S. (1961). Some parameters of verbal affect responses in schizophrenic subjects. Journal of Abnormal and Social Psychology, 63(3), 511-516.
Salzinger, K., & Pisoni, S. (1958). Reinforcement of affect responses of schizophrenics during the clinical interview. Journal of Abnormal and Social Psychology, 57(1), 84-90.
Stahl, J. R., & Leitenberg, H. (1976). Behavioral treatment of the chronic mental hospital patient. In H. Leitenberg (Ed.), Handbook of behavior modification and therapy (pp. 211-241). Englewood Cliffs, NJ: Prentice-Hall.
Stephen Wong (2006). Behavior analysis of psychotic disorders: Scientific dead end or casualty of the mental health political economy? Behavior and Social Issues, 15, 152-177.
16 Monday Apr 2018
Posted in adults, Behavior Analysis, Community, Education, ethics, functional alternative behavior, RAD, reactive attachment disorder, risk assessment, schedules of punishment, self injurious behavior, stimulus schedules, supervision, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized
Tags
BACB Ethics code, BACB Task List, punishment, schedules of punishment, school to prison pipeline, stimulus schedules
(Part 13 of a series of posts about Trauma-informed behavior analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)
Preventing and addressing connections between educational problems, trauma and mental health needs, and the legal system
Perhaps you are familiar with laws making it a crime to assault a medical worker in their line of work. Even the most caring mental health nurse may need to report injuries that occurred helping restrain a confused, drugged, juvenile patient who was suffering from mental health problems, preventing the client from self-harm. Of course, this difficulty isn’t the only way for a special education student to end up with traumatic effects of past interactions that are compounded by legal charges. Why do so many children go from getting kicked out of preschool, through a series of failed educational and residential placements as a teen, to facing jail time before they are fully adults? After hearing Matthew Bennett and friends’ podcast on trauma and criminal thinking, I was inspired to write a behavioral response to share some thoughts for our community.
While behavior analysts and collaborators may be well versed in “schedules of reinforcement”, another type of schedule matters too. This other kind of schedule is in place all around us, is often acting to viciously increase the likelihood of future problems, and may be invisible to most of the educators, foster parents, and even behavior therapists “trying to do the right thing.
We’re talking about schedules of “stimulus delivery” or schedules of interaction. In short, this kind of schedule makes a great deal of difference, whether it is “programmed” (planned in advance) or simply happens— and whether the stimulus is a member of the police, a school or hospital security guard, or the school principal. Even if we are talking about events that are recommended by a response team or safety plan, such as a foster parent coming to pick up a student after behavior is too severe for the school, or physical holds and restraints that take place to keep others safe, all these events can have powerful effects (or side effects) in the behavior stream.
Why do we talk about these events in terms of the “schedule”? In behavior analysis, a “schedule” can refer to the timing of stimulus delivery. For example, suppose a student’s safety plan states that after a certain behavior occurs, a parent will be called. The next few times it happens, the principal will be called in to talk with the student. After that, a safety officer will be called to escort the student off grounds and he will be asked to stay home for 2 days. Suppose this proceeds over the course of about a year, and by the spring semester his challenging behavior has escalated and the last few times, a security guard is not sufficient and the police are called. The “schedule” of delivery might specify that at least one of these things happens every time the behavior occurs… that would be a fixed or continuous schedule. But more commonly, some behaviors are missed, or there is an unfamiliar substitute teacher who doesn’t act immediately and implement the plan, or some similar behaviors occur at home or in someone else’s class but are not treated the same way as the same behavior would at school in the classroom for which the plan was designed.
In fact, research shows that escalating “punishment”, or in other words, using more and more severe consequences over time, can actually increase behavior! This fact, well known to behavior analysts, surprises many educators who thought their prescribed plan would decrease behavior, not escalate it. Specifically, the research shows that if a stimulus is used because the team wants to decrease a behavior (and “decreasing a behavior” is called “punishment” in the literature, even if the team members don’t consider it that way), it is critical that the stimulus is intensive enough for it to be effective (Lerman and Vorndran, 2002), used every time the behavior occurs (Acker and O’Leary 1988), and used consistently and across environments. If used inconsistently, it will likely INCREASE the behavior (Tarbox, Wallace and Tarbox, 2002).
Unfortunately, this common situation has several side effects. For example, the following can all result:
As shocking as this may be to families and educators using these systems every day, the results do not surprise a behavior scientist familiar with the literature. Young or inexperienced clinical behavior analysts may not have been exposed to these cold facts, doing harm by not pointing out the risks inherent in many well-meaning school behavior plans or facility safety plans. Did you know a BCBA’s training IS required to include exposure to how to properly implement “parameters and schedules of punishment” (see BACB Fourth Edition Task List, item D-17)?. This means that in cases where punishment, or a consequence based strategy to decrease behavior, is needed (e.g., determined via a risk assessment to be necessary), we must determine ways to avoid escalating behavior (see also section 3.01 and 4.08 in Compliance Code, on the requirements for assessment before reduction procedures, and considerations regarding punishment procedures).
Are you a behavior analyst who hasn’t yet received this kind of important training, or an educator with behavior analysts on your team who haven’t mentioned this? Some suggestions are below for finding a starting place in the literature. Behavior analysts should be familiar with all task list and compliance code requirements for appropriately implementing punishment. Educators might check out this Edutopia piece discussing the use of discipline instead of punishment. A behavior analyst will work hard to avoid punishment. Instead, we begin with a functional behavior assessment that truly illuminates what the child needs and is trying to communicate, in order to build a plan fostering functional communication and coping skills.
Here are some topics to bring up or request supervision on:
Practical skills for teams
Closing thoughts:
When making placement decisions, the cheapest or first option available may not be appropriate if it contributes to long term risks for the client and community. Many times, a placement decision is made based on promises to get training and keep the client safe as long as nothing goes wrong. In fact, things WILL go wrong (e.g., it should be predicted and planned for). So risk assessments are critical in placement decisions. Teams must be transparent about the short and long term risks of environments that expose clients to models of behavior that is aggressive or destructive. And placement decisions to accept or remove a client due to inappropriate behavior should be evaluated with respect to the function of behavior and long term risks. Is this likely to increase similar behavior, producing long term likelihood of using aggressive attempts to escape environments? Does the team and environment have the ability to support the client to return to the setting after temporary removal due to aggression to others?
When we are thoughtful, collaborative and function-based, we can contribute to slowing the rushing pipeline carrying our clients and family members into more restrictive settings, and exposing them to more severe consequences. Let me know if some of these suggestions educated your team to coordinate behavior support and safety plans that are more appropriate, compassionate and preventative—and please share your own ideas that have worked.
References
Behavior Analysis Certification Board BCBA and BCaBA Task List, Fourth Edition:
Behavior Analysis Certification Board Compliance Code (2016):
https://www.bacb.com/wp-content/uploads/2017/09/170706-compliance-code-english.pdf
Acker, M. M., & O’Leary, S. G. (1988). Effects of consistent and inconsistent feedback on inappropriate child behavior. Behavior Therapy, 19, 619-624.
Lerman, D. C., & Vorndran, C. M. (2002). On the Status of Knowledge for Using Punishment: Implications for Treating Behavior Disorders. Journal of Applied Behavior Analysis, 35, 431- 464. http://dx.doi.org/10.1901/jaba.2002.35-431
Tarbox, Wallace, and Tarbox (2002). Successful generalized parent training and failed schedule thinning of response blocking for automatically maintained object mouthing. Behavioral Interventions, 17 (3), 169-178.
Lori Desautels (2018). Aiming for Discipline Instead of Punishment, Edutopia, published online March 1, 2018. https://www.edutopia.org/article/aiming-discipline-instead-punishment
Trauma-informed lens podcast: https://connectingparadigms.org/podcast/episode-25-trauma-criminal-thinking/
20 Tuesday Mar 2018
Whether you’ve been in the field for a year or twenty, and whether you feel like you make a difference each day, or struggle to go to work, anyone can benefit from deliberately expanding their boundary of competence. Perhaps you’ve had calls from a potential client and had to turn down the opportunity, lacking the experience, training, supervision, funds, or continuing education to say yes, or to provide treatment for that particular diagnosis, age group, type of agency or setting, or behavior. If you can identify, you are not alone. In my recent poll of a group of behavior analysis students in a post-master’s degree course that counted toward the BACB requirements for sitting for the exam, 100% of students identified that they were currently working in the autism field. Despite their lack of exposure to other fields, there was certainly no lack of interest! 40% of students were interested in getting involved in education; 88% of students wanted to know more about behavior analysis in animal welfare; and 63% wanted to learn more about behavior analysis in child welfare and human services, including intellectual disabilities. Seventy-five percent of students would have liked to expand into behavioral gerontology, 69% into behavior-based safety, and 56% into organizational behavior management. And a full 100% indicated they were interested in learning how they could use behavior analysis to support those with brain injury!
With this diversity in the interests of entry level certificants (and an array of actual jobs that is even more rich), it is always amusing and a little surprising to see this frequent question on social media: “is there anyone here who practices outside of autism (or its cousin early intervention)? If so, how could I grow my practice?”
Fortunately, the same foundational knowledge, skills and tools that helped you to grow your clients’ repertoire apply to this opportunity that you face. Maybe you’re thinking this is easier said than done. But stick with me… maybe that’s just the initial impression you’re getting from the seeming lack of exemplars. Let’s talk about a skill that’s already in your repertoire: arranging a supportive environment for doing something new.
First, it might help to connect with your “values”, goals, or reinforcers (see this article on values in behavior analysis using the ACT (Acceptance and Commitment Therapy) framework). Or you might find it helpful to jot down your answers to questions like this: What do you want to be doing in 5 years? What is one thing that if you began to do it, your entire life would change? Who do you most want to help in your lifetime? What gets you so jazzed up you can’t stop talking about it? Israel Goldiamond, the father of the Constructional Approach, asked similar questions in his Constructional Questionnaire. I think of this as the best motivational interview out there, and you can find it around the end of his wonderful 1974 article, reprinted in 2002 here (see page 187). He wanted to know, “assuming we were successful, what would the outcome be for you?” Another way of asking this question is to ask yourself what “cusp” you need most to achieve your goals. (See this article on how identifying a behavioral cusp can help you make leaps of progress.)
Now that you have gotten in touch with your “why”, you need to arrange some ways to contact related reinforcers, and to see exemplars in action. Just as a video model helps my 13 year old client learn to make a sandwich and see the results – consuming the delicious hand made treat—I was inspired and more, when I broke out of my comfort zone and attended conference talks that only remotely applied to my then-current work in autism. I watched OBM talks, animal talks, behavior safety and gerontology talks, and went to every talk on behavior analysis in mental health that I could find. RELATED TIP: At conferences, approach speakers who inspire you from different and related fields. Ask them for suggestions. Select a recommendation, apply it for several weeks, and contact the person to follow up and thank them.
When first branching out (or planning your leap), I recommend that you spend some time dedicated to being a generalist. Nearly every area has at least some agencies that support people with developmental disabilities or differently abled people of all ages. Around Colorado, I can do this by connecting with Community Center Boards, ARC’s, and county organizations. If you don’t find full time opportunities for paid work with these organizations, you can gain the same benefit through volunteering at an agency similar to those I have named. The great benefit of this suggestion is that you rapidly move beyond being “a person with experience with autism and early intervention”, to someone who has been around inclusive support of people with an array of developmental, intellectual, and genetic challenges. Doing this step before working on my own meant that I was now experienced with all ages and settings where people might experience treatment, ranging from private residences, host homes, group homes and mental hospitals, to all kinds of day programs.
Next, I encourage others in the “before you leap” stage to begin to collaborate intensively and intentionally. You can do this wherever you are, of course. I can’t count how many letters I have written to the client’s pediatrician, physician, dentist, feeding therapist, psychotherapist, occupational and speech therapist, advocate, social worker, police department, psychiatrist, psychologist, adoptive caseworker, and nurses. When and why do I do this? I initiate the contact to surrounding professionals (when appropriate and after obtaining written permission from the guardian, of course (see Compliance Code Guideline 2.03 and 3) at the onset of a case when I am conducting my documentation review, as part of the FBA (Functional Behavior Assessment). I do this to let the potential collaborator know I am doing an assessment in case it impacts or informs their own clinical work, and request documentation if needed for my assessment. I don’t always hear back. But when I do, these connections grow my network and enhance the client’s collaborative care. And the professional may write months or years later and ask for collaboration or consultation or training for their staff!
At the end of services, a report may not be required. But write it anyway. It helps to document the closing or transfer of a case in an appropriate way, and provides a way for you to leave your information for all parties in case someone wants you to collaborate in the future. Be sure to add the 3 R’s: Always embed resources, risk assessments, and referrals in your reports. The risk assessment piece has helped me grow my career in several ways. First, it’s just plain good (and ethical) practice to document the risks and potential benefits of current and other possible options for what your client is considering. But it’s also a little new to the field; it’s not quite standard practice although it’s a standard recommendation. I have had referrals to do educational evaluations and consultation for companies and agencies who happened to see one of my risk assessments embedded in a report.
RELATED TIP: Graph other people’s interventions. You already know you’re responsible for helping understand the effects of related interventions if the client is receiving more than ABA. But this is also hugely educational for the other professional, and fosters future relationships. What psychiatrist wouldn’t appreciate a cumulative record of challenging behavior or new words learned, with lines on the graph showing her when the medication changes occurred? What social worker would turn down a graph of her home visits and the child’s family interaction, superimposed on a graph of the client’s challenging behavior? What school teacher wouldn’t appreciate a graph of new skills learned at home at the same time as school interventions were occurring?
The above tip only works as long as we respect others and value others’ work. Try to learn about it before you offer to help or intervene, never ask a team to take data before looking at (and perhaps graphing) what data they are already collecting. And I like to enter any environment with a “tips sheet” that puts into words some basic strategies that will help promote appropriate behavior, leaving them with my contact information and availability to collaborate if they need support or want to learn more about behavior analysis. (See this earlier post on collaborating within hospital environments for similar ideas).
Tips for entering a provider network that you’re not familiar with: You can contact a caseworker for the agency and ask to speak with someone in their administration. Or you can ask how people become providers. Usually there is an upcoming provider fair in the next few months you can get invited to. Finally, ask if they have support groups for families or clients; ask if you can audit a support group to learn more about their needs. Be quiet and respectful during this time that families are sharing, and think about ways you would be able to support them. Don’t ambulance chase; follow the ethics code and find other routes. (While you wait you can apply to be a provider, and offer to do a free basic training on behavior analysis and how clients can benefit). The agency may start connecting you to families at that point.
Give back and stay connected. I practice these tips regularly: find a mentor, meeting with someone regularly who can guide you. At the same time, I meet regularly with people who likely can’t help me, but to whom I can be a good source of advice or support. At any level you can do this; BCaBA’s can help to mentor an RBT; BCBA’s can mentor BCaBA’s and RBT’s; and BCBA-D’s can mentor each other, and BCBA’s. Sometimes finding a complementary professional who is in a field that’s only slightly related can be a great source of networking and support, as I find with professional friends who are not behavior analysts but who are mental health therapists, psychiatrists, and psychologists.
Some final thoughts: Ask for supervision and mentorship actively. (We live in an age where you can easily have phone or internet meetings with someone across the globe whose experience you lack.) Give referrals to others (help others grow their networks). Read articles, and attend conference meetings, slightly out of your field. Check out what other behavior analysis professionals have to say about expanding boundaries. Contact conference presenters. Trust me, we usually welcome it. Be interested in other people and their work, research, articles, podcasts, what they love to talk about. DO give a firm “no” before, not when, you are overloaded (this helps you do a good job in every case). When you have to say no, teach people how to locate a behavior analyst in their area. Keep growing your skillset (my current frontier is an ACT supervision group I have joined with therapists who are not behavior analysts). And finally, try keeping a yes/no log! This is a place to write down the contact information, date and nature of any referrals or opportunities you received, that you must turn down because you still lack the mentorship, experience, continuing education, training or supervision. Check whether the opportunity aligns with your values and goals (see the first step we discussed today). If it does, then program for yourself an action plan in which you identify at least three actions that put you closer to saying “yes” to similar opportunities in one year. One year later, check in with the old referral and let them know you appreciate the ways they helped you grow and that you’d be happy to meet for tea to hear how they are doing.
If this post helped you, let me know how YOU are doing… or feel free to write me and add suggestions and solutions you have found. May we all keep growing!
Resources
LeBlanc et al. (2012) on expanding the consumer base for behavior analytic services
Website on Goldiamond’s Constructional Approach: https://behavioranalysishistory.pbworks.com/f/The%20Constructional%20Approach.pdf
Goldiamond’s article Toward a Constructional Approach to Social Problems (you can download the PDF by first going to this page):
http://journals.uic.edu/ojs/index.php/bsi/article/view/92
Article on “values” in behavior analysis using the ACT framework:
Article on ACT and behavioral activation related to depression and avoidance:
