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Category Archives: enriched environment

Contraindicated behavioral procedures after trauma

08 Tuesday Sep 2020

Posted by kolubcbad in adults, Behavior Analysis, collaboration, continuing education, contraindicated procedures, Education and Trauma-Informed Behavior Analysis, enriched environment, mental health, praise, RAD, reactive attachment disorder, risk versus benefit analysis, schedules of punishment, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

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contraindicated procedures, trauma, trauma-informed behavior analysis

This is the 20th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D

In medicine, contraindicated procedures are those that are withheld due to the potential harm they might cause to a patient. More and more, behavior analysts are interested in learning about someone’s history, in part to lessen the risk they will do a client harm.

We are tasked, ethically, to do no harm (and see the BACB Ethical and Professional Code item 4.02); to evaluate potential risks and side effects of interventions and to weigh the possible benefits of each (see 2.09 and 4.05); and to avoid using harmful reinforcers or those that require excessive motivating operations to be effective (4.10).  For RBTs as well as those certified at higher levels, ethics obligates us to protect our clients from harm (see RBT Ethics Code section 2.02).

In our live webinars (please see CuspEmergenceUniversity.com where we list topics we train frequently on– any course you see there is available as a live webinar training or, in some cases, available as an on-demand training), we receive frequent questions like this:

What kind of procedures should be avoided when working with a new client after certain types of trauma? Are there certain procedures we should give more thought to after a client has been through challenges we know about? What do we do if so?

Given these wonderful questions, today’s post shares a few basic procedures that may be contraindicated – at least at first—given a specific combination of historical factors involving trauma.

Of course, it’s not black and white. Often this should just be the first step for the team, a conversation in which people consider potential for risk conferred by historical variables. The team can then make a more careful decision in order to mitigate possible risks and maximize the benefit of any procedures selected, along the lines of what our code suggests in item 4.05. Though each procedure below is potentially contraindicated at first, it could be appropriate later in treatment, or perhaps from the beginning- the point is that this should depend on an individualized risk versus benefit analysis of the other options available to the team, the client’s history and needs, the severity of the past abuse or neglect or trauma, etc.

  1. For a client who has experienced previous food insecurity, food related abuse or neglect, and/or severe food deprivation:

One potentially contraindicated procedure is using edible reinforcers.

Notes: Here there are risks to the client, and also potential risks to the client’s relationship with their caregivers and team members. The conditions necessary to establish the motivating operation for reinforcement may be similar to previously neglectful or abusive conditions, or may act as conditioned motivating operations that make harmful behaviors temporarily more likely. In our history treating clients after these circumstances, we have also experienced something related to behavioral contrast in this situation. For example, a client who was provided edible reinforcement in their new applied behavior analysis setting then went home and used dangerous and surprising behaviors related to their neglectful history. The client’s foster family was caught off-guard by these new behaviors, but they could have been predicted during team education on how edible reinforcers might need to be avoided at first when conditioning new team members as reinforcing (and as instruction-related discriminative stimuli).  

2. For a client who has been involved in previous sexual abuse (including when the client also makes allegations):

One contraindicated procedure is assigning a 1:1 without additional oversight.

Notes: Here there are risks to both the client and additional team members. When the team receives this case, it would be contraindicated to immediately assign 1:1 support without preventative measures such as training for the 1:1 and supplemental recording, additional oversight or whatever is deemed necessary.

3. For a client who has experienced medical complications from sexual or physical trauma (e.g., this could include incontinence, fecal smearing or related concerns, etc):

One contraindicated procedure is conducting toilet training without oversight from a medical professional, additional training or consultation by someone with expertise in this circumstance, etc.

Notes: In this situation, respondent and operant interactions can occur that are dangerous to treat without expertise; the client can risk serious complications and worsening medical problems; there is a risk of further conditioning the experiences of voiding (and related rituals) as aversive; there is a risk of occasioning behaviors related to the past abuse, or pairing aversive events with team members involved in the procedures; and more.

4. For a client who has experienced previous neglect or adverse circumstances (such as deaths of parents, removal from unsafe conditions, or experiencing war, dangerous immigration or poverty related issues), resulting in deprivation of basic needs and social interaction:   

Some potentially contraindicated procedures involve attention related extinction, differential reinforcement of appropriate versus inappropriate requests, or time out from attention reinforcement.

Notes: In this situation, there are safer procedures to begin using that could avoid some of the harmful side effects of removing attention contingent on unsafe behavior. A child with a serious history of neglect may have used behaviors that can seem bizarre or out of context for typical child development, but that were critical to the child’s survival. At the same time, it may not be appropriate to pair new team members with procedures that were used in the child’s neglect, even if the “intent” is different. There are many procedures that can be used more safely, such as using enriched environments and fixed time schedules, to provide monitoring, insure high levels of safe attention, and begin to condition adults as neutral stimuli again, if needed, after harmful interactions with adults in the person’s past.

5. For a client who has been affected by physical and/or sexual abuse, behaviors and circumstances consistent with reactive attachment disorder, or multiple and changing caregivers in childhood:

One potentially contraindicated procedure might be contingent praise statements to establish compliance related behaviors.

Notes: In this situation, a client may have had a history in which adults could not be trusted, behaved inconsistently or inappropriately, or paired unsafe and harmful actions with typical caregiving behaviors. Clients who experienced this may initially present as lacking “a compliance repertoire”, but it may be contraindicated to attempt to establish and praise compliance, for several reasons. Some may be overly compliant, and lack self-help and self-advocacy repertoires that are critical to autonomy; if they are still going home at night after the school day to an unstable situation or multiple foster homes, to praise rigid compliance may increase the risk of further victimization or contribute to future abuse. At the same time, initial praise for compliance may damage relationships between the client and new caregivers who have not “earned” the right to praise the client’s behavior by establishing a history of consistency and helpful interactions. Furthermore, praise might already be conditioned as aversive for the client and could sabotage the caregiver’s attempts to establish a relationship or instruct appropriate behavior. (CuspEmergence.com has written elsewhere about praise here).

6. For a client who has been affected by neglect, and involved with law enforcement, suspensions and challenging behavior:

A potentially contraindicated procedure is least to most punishment.

Notes: Implementing punitive procedures (or procedures that educators assume to be aversive and are using to control behavior) in a “least-to-most” order is dangerous, especially after the interactions mentioned here. Any time punishment is implemented in a LTM order, we risk these outcomes: conditioning the aversive stimuli becoming more reinforcing, and more familiar; worsening the client’s behavior as they need to contact more and more of the supposedly aversive stimulus; pairing the people administering the punishment with aversive control, making it more likely the client will (to speak loosely) act out more and more for their high-quality attention; etc. (CuspEmergence.com has written about the potential pipeline from special education to prison here, in an article referencing some of these concerns and containing behavior analytic references.)

7. For a client with symptoms or diagnosis of trauma-related disorders or needs:

A potentially contraindicated thing to do is recommending or implementing applied behavior analysis without any mental health or trauma-focused treatment or input.

Notes: Behavior analysis (at least the kind I provide and teach about) is not a trauma treatment. We are also not a source of diagnosis for trauma. Instead, I work in a complementary way with a team and/or family that is interested in learning about risks related to trauma history, and how these risks affect the person’s behavior, needs, and supports. There are therapies that can provide trauma-focused treatment and aid a person to heal after experiencing difficult circumstances; a person may need these in addition to, or before, receiving behavior analysis to aid them in developing a safe, expanded behavioral repertoire. If someone trusts you with their trauma history, please be careful and supportive.

In closing, for a client with a specific conditioning history, the contraindicated procedure would likely involve aversive conditions and potentially medical or biological variables. Always consider items 3.02 and 4.08 from our Professional and Ethical Code, and discuss whether they apply to your case:

3.02 Medical Consultation. Behavior analysts recommend seeking a medical consultation if there is any reasonable possibility that a referred behavior is influenced by medical or biological variables.

4.08 (d): Behavior analysts ensure that aversive procedures are accompanied by an increased level of training, supervision, and oversight. Behavior analysts must evaluate the effectiveness of aversive procedures in a timely manner and modify the behavior-change program if it is ineffective. Behavior analysts always include a plan to discontinue the use of aversive procedures when no longer needed.”

Part 14 in Trauma-Informed Behavior Analysis: Intersections with Mental Health

21 Monday May 2018

Posted by kolubcbad in adults, Behavior Analysis, boundaries of competence, collaboration, Community, enriched environment, mental health, supervision, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized

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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 cof

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.

 

Part 9 in Trauma-Informed Behavior Analysis: On intervention for fetal alcohol exposure

18 Monday Sep 2017

Posted by kolubcbad in adults, Behavior Analysis, children, Early Intervention, Education, enriched environment, FAS, FASD, Fetal Alcohol Spectrum Disorders, risk assessment, self injurious behavior, Social Interaction, teaching ethics, trauma, Uncategorized

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aggression, behavior analysis, early intervention, FAS, FASD, Fetal Alcohol Spectrum Disorders, fetal alcohol syndrome

Early intervention after an unfair start in life: Fetal exposure to alcohol

Those of us who work with people who have lived through adverse childhood experiences are familiar with the importance of individualizing treatment. We can do a lot of harm if we don’t consider what someone went through in life, or if we assume that one child’s preferences and needs are similar to those of another person.

Of course, this series about trauma has emphasized that it is the responsibility of ANY behavior analyst to individualize treatment, to consider the history of a client before moving forward with treatment, and to treat more than the “local” functions of behavior. Unfortunately, it is easy to miss the importance of this component of assessment and treatment, especially for new behavior analysts who have gained their “hours” working with highly similar clients, working without supervisors experienced in a diverse clientele, of without any supervisor or instructor who appreciates experimental as well as applied behavior analysis. One of the ways we find out more, is to go to the literature. This may be easier said than done, and an example of successfully data mining for this topic is provided toward the end of the article.

Today’s discussion involves clients who have been affected by what’s known as “Fetal alcohol syndrome”, or exposure to alcohol in the womb.

This is more than adverse childhood experience, for it goes back further in development, perhaps even as early as the neural tube (which will give rise to the spinal cord) and other important structures were being formed. This kind of exposure can affect an individual for their entire lifetime.

So we can consider it an adverse experience, although it happened even earlier than what we think of as “childhood”, and it has long lasting consequences, altering the way someone will learn and interact for the rest of their life.

Can we treat behavior after this condition? Continue reading →

Resource Wednesday: Paradigm Behavior, for family-supportive resources beautifully designed by a friendly BCBA

09 Wednesday Aug 2017

Posted by kolubcbad in Autism, Behavior Analysis, children, Early Intervention, Education, enriched environment, play, resources, Social Interaction, teaching behavior analysis, Uncategorized

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behavior analysis, children, community, paradigm behavior, parents, play, resources, teaching behavior analysis

At CuspEmergence, we love finding resources or information we can share with our families and community. Imagine our excitement when we discovered this close-to-home resource, an entire website devoted to helping parents become even more amazing at playing, communicating, and connecting with their children! Paradigm Behavior maintains a website and resource library where families can learn, with the support of a Board Certified Behavior Analyst who is a parent herself. Christina posts blogs, resources for supporting play, and online coaching for families interested in developing play skills, language, and more. Paradigm Behavior maintains a well-stocked Playroom, which could teach students and supervisees cutting their teeth in behavior analysts a thing or about connecting with families and using materials in effective ways.

The resources we found were helpful even to seasoned behavior analysts, taking much of the work out of connecting parents with individualized resources that were at once friendly and helpful. We think you’ll love them as much as we do

Check out ParadigmBehavior.com.

Trauma-informed behavior analysis, Part 2: Arranging a supportive behavioral environment

03 Thursday Aug 2017

Posted by kolubcbad in adults, Behavior Analysis, Behavioral Cusp, enriched environment, ethics, supervision, teaching behavior analysis, teaching ethics, trauma, Uncategorized

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(Continued from Part 1 of Trauma-informed behavior analysis series by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)

pencil_three years old (2)

Part 2, Engineering Supportive Environments

On arranging the environment

What does it mean to arrange the environment in a preventative way? This means to think about everything someone needs, and how they get it or communicate that they need it. After we consider this piece, we see holes in the behavioral environment.

If these holes go unfilled, the person will likely do whatever they need to do to fill them, often in a way that is ultimately unproductive and painful for themselves or others.

In a way, everyone is doing the best they can, all the time.

So in considering what someone needs in advance, we can find ways to plug in something helpful where it is needed, in a preventative way. This means that before someone needs something, an observant caregiver or friend may recognize the need is coming, and begin to set up the surroundings so that need is being filled. Before someone falls in the well, we fill up the well with concrete and make it so that they cannot fall in — even if they step right on top of it. For example 1 in Part 1, the client who was left alone in the dark is given preventative repertoire building, and taught skills that help her to cope each night with the coming darkness. Her caregivers are taught new repertoires, learning to announce their presence and ask her permission before entering; to problem solve with her instead of forcing the next event on her; and to check in in a preventative way to see if she needs anything, instead of responding with force when something is already going wrong. Eventually, she learns to ask for help before it gets to a crisis, to soothe herself to sleep instead of showing agitation leading to support going to bed, and to problem solve by herself when about to face a known triggering event. Continue reading →

Self Injury in the General Population: Will I hurt myself today?

01 Tuesday Aug 2017

Posted by kolubcbad in adults, Behavior Analysis, Community, enriched environment, functional alternative behavior, self injurious behavior, trauma, Uncategorized

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Will I hurt myself today… Or do something (F.A.B.) instead?

Time for a Trauma Tuesday post. But this one is not what you think.

By this time, most people have heard the notion that those who have been hurt may be more at risk to hurt others.

In my work with clients who have been through childhood abuse, mistreatment and neglect, I often see the tragic pattern they try to stop, often failing because of a lack of resources, or knowledge about what to do differently.

And on our caseloads with clients with autism or developmental disabilities, we frequently treat another kind of pain, the kind that a person produces for themselves and often related to the challenging environments in which our clients live, or a lack of skill in expressing one’s needs. In our field, hurting oneself is known as “self-injury” or SIB (self-injurious behavior).

However, this post is not about treating SIB in our clients, although there are many resources for doing this, and your friendly local behavior analyst can do a functional behavior assessment to determine where to start, before making an individualized plan.

This post is about something else that is common, yet hidden.

Recently in a women’s empowerment group for supposedly “neurotypical” people, a behavior analyst was stunned when 75 percent of hands went up as the question was asked, “how many of us have actually hurt ourselves, or do this on a regular basis?”

Today, my question for us is, what about the pain all around us? What about self injury in the general population? Continue reading →

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