Individual Biases and Cultural Humility and Diversity (200-300 words)

SPECIAL SECTION: DIVERSITY AND INCLUSION

Cultural Humility in the Practice of Applied Behavior Analysis

Patricia I. Wright1

# Association for Behavior Analysis International 2019

Abstract Applied behavior analysis (ABA) has the intent to improve the human condition in a broad range of categories of practice and for diverse groups of individuals across cultures. The data on the diversity of the professionals practicing in the field of ABA are sparse. Access to ABA intervention is inequitable, and cultural differences are not adequately addressed in many current established behavioral interventions. Cultural humility is a framework used by other professional disciplines to address both institutional and individual behavior that contributes to the power imbalance, the marginalization of communities, and disparities in health access and outcomes. This article discusses the adoption of culturally humble practices, specifically through the use of self-reflection, by the field of ABA to address disparities and improve outcomes. A specific framework from the field of social work is shared, and an adaptation to the behavior-analytic practice of self-management is provided.

Keywords Social service . Disability . Cultural humility . Applied behavior analysis . Self-reflection

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

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

For the purposes of this article, the core elements of cultural humility in Fisher-Borne et al.’s (2015) model—individual accountability and institutional accountability—will be used as a framework for considering its application to ABA. This model assumes there are power imbalances that both individ- uals and institutions must work to address through ongoing learning and critical self-reflection. Although Fisher-Borne et al.’s model was developed for the field of social work, it is applicable to the work of applied behavior analysts. ABA, like social work, is dedicated to addressing socially significant behaviors that improve the human condition (Baer, Wolf, & Risley, 1968, 1987; National Association of Social Workers, 2018). Behavior analysts have individual responsibility as de- fined by the Professional and Ethical Compliance Code for Behavior Analysts (Behavior Analyst Certification Board, 2017), and both fields have established institutions that deliver

* Patricia I. Wright [email protected]

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

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

18 October 2019Published online:

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

The Application of Cultural Humility in ABA

Professional Ethics

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

1.05 Professional and Scientific Relationships.

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

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

Ongoing Learning and Critical Self-Reflection Using Self-Management

The models of cultural competence and cultural humility are found outside of the field of behavior analysis; however, behavior analysts are beginning to voice the importance of cultural competence within their scope of practice. Fong, Catagnus, Brodhead, Quigley, and Field (2016) published an initial paper on the topic that was stated to serve as a starting point for developing behavior analysts’ cultural awareness skills. Beaulieu, Addington, and Almeida (2018) conducted a survey of 703 Board Certified Behavior Analysts to learn about the extent of training for working with individuals from diverse backgrounds, the perceived importance of training on the topic, and the degree to which practitioners felt comfort- able and skilled in the delivery of culturally competent inter- vention. The majority of respondents felt moderately or ex- tremely comfortable and reported they were moderately or extremely skilled at working with individuals from diverse backgrounds. However, the majority of respondents also re- ported having little or no training in cultural competence. This reported confidence without training may be indicative of a need for behavior analysts to evaluate with greater scrutiny the application of cultural competence in their practice. One strat- egy to address cultural competence and humility within the practice of behavior analysis is to review how other profes- sional fields adopt culturally humble practices and assess the appropriateness of these practices for behavior analysis.

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

Behav Analysis Practice (2019) 12:805–809806

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

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

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

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

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

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

Table 1. Individual and Organizational Questions to Assess Cultural Humility

Essential questions for critical self-reflection Essential questions to address power imbalances

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

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

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

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

clients who are different than me?

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

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

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

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

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

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

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

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

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

communities we serve?

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

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

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

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

• How do we engage with the larger community to ensure community voice in our work? What organizations are already doing this well?

Note. Reprinted from “Mastery to Accountability: Cultural Humility as an Alternative to Cultural Competence,” by M. Fisher-Borne, J. Caine, and S. Martin, 2015, Social Work Education, 34, p. 176

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

nonbehavioral terms of trauma-informed care (e.g., promoting a safe environment) into behavioral practices (e.g., environ- mental arrangement as a setting event). An understanding of the behavioral principles of trauma-informed care to which the other team members are attributing the student’s success might lead a behavior analyst to want to describe the observed effects in behavioral terms. However, use of behavior-analytic terms can create a barrier among team members without behavior- analytic training, as behavior-analytic language can be per- ceived as harsh or unpleasant (Critchfield et al., 2017). Refraining from reframing the practice in behavioral terms may increase the likelihood of positive interactions with other team members while collaborating on this case.

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

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

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

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

Discussion

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

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

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

Behav Analysis Practice (2019) 12:805–809808

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

Funding The author received no specific funding for this work.

Compliance with Ethical Standards

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

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

References

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimen- sions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, 91–97. https://doi.org/10.1901/jaba.1968.1-91.

Baer, D. M., Wolf, M. M., & Risley, T. R. (1987). Some still-current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 3(20), 13–327. https://doi.org/10.1901/jaba. 1987.20-313.

Beaulieu, L., Addington, J., & Almeida, D. (2018). Behavior analysts’ training and practices regarding cultural diversity: The case for cul- turally competent care. Behavior Analysis in Practice. https://doi. org/10.1007/s40617-018-00313-6.

Behavior Analyst Certification Board. (2017). Professional and ethical compliance code for behavior analysts. Retrieved from https:// www.bacb.com/wp-content/uploads/2017/09/170706-compliance- code-english.pdf

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper Saddle River: Prentice Hall.

Critchfield, T. S., Doepke, K. J., Epting, K., Becirevic, A., Reed, D. D., Fienup, D. M., et al. (2017). Normative emotional responses to behavior analysis jargon or how not to use words to win friends and influence people. Behavior Analysis in Practice, 10, 97–106. https://doi.org/10.1007/s40617-016-0161-9.

Donaldson, A. L., Stahmer, A. C., Nippold, M., & Camara, S. (2014). Team collaboration: The use of behavioral principles for serving students with ASD. Language, Speech & Hearing Services in Schools, 45, 261–276. https://doi.org/10.1044/2014_LSHSS-14- 0038

Fahlberg, B., Foronda, C., & Baptiste, D. (2016). Cultural humility: The key to patient/family partnerships for making difficult decisions.

Nursing, 46, 14–16. https://doi.org/10.1097/01.NURSE. 0000490221.61685.e1.

Fallon, L., O’Keefe, R., & Sugai, G. (2012). Consideration of culture and context in school-wide positive behavior support: A review of cur- rent literature. Journal of Positive Behavior Interventions, 14, 209– 219. https://doi.org/10.1177/1098300711426334.

Fisher-Borne, M., Cain, J., & Martin, S. (2015). From mastery to account- ability: Cultural humility as an alternative to cultural competence. Social Work Education, 34, 165–181. https://doi.org/10.1080/ 02615479.2014.977244.

Fong, E. H., Catagnus, R., Brodhead, M., Quigley, S., & Field, S. (2016). Developing the cultural awareness skills of behavior analysts. Behavior Analysis in Practice, 9, 84–94. https://doi.org/10.1007/ s40617-016-0111-6.

Freshman, B. (2016). Cultural competency: Best intentions are not good enough. Diversity and Equality in Health Care, 13, 240–244. https:// doi.org/10.21767/2049-5471.1000e17

Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., Jr., & Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology, 60, 353–366. https://doi. org/10.1037/a0032595.

Kelly, A., & Tincani, M. (2013). Collaborative training and practice among applied behavior analysts who support individuals with au- tism spectrum disorder. Education and Training in Autism and Developmental Disabilities, 48, 120–131.

Koh, H., Garcia, N., & Alvarez, M. (2014). Culturally and linguistically appropriate services: Advancing health with CLAS. The New England Journal of Medicine, 371, 198–201.

National Association of Social Workers. (2018). Retrieved from https:// www.socialworkers.org/Careers/Career-Center/Explore-Social- Work/WhyChoose-the-Social-Work-Profession

Nguyen, C., Krakowia, P., Hansen, R., Hertz-Picciotto, I., & Ankustisiri, K. (2016). Sociodemographic disparities in intervention service uti- lization in families of children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46, 3729–3738. https://doi.org/10.1007/s10803-016-2913-3.

Nomikoudis, M., & Starr, M. (2016). Cultural humility in education and work: A valuable approach for teachers, learners and professionals. In J. Arvanitakis & D. J. Hornsby (Eds.), Universities, the citizen scholar and the future of higher education. London: Palgrave Macmillan. p. 69-84. https://doi.org/10.1057/9781137538697_6.

Nosik, M., Luke, M., & Carr, J. (2018). Representation of women in behavior analysis: An empirical analysis. Advance online publica- tion. Behavior Analysis: Research and Practice. https://doi.org/10. 1037/bar0000118.

Stone, J., & Moskowitz, G. B. (2011). Non-conscious bias in medical decision making: What can be done to rescue it? Medical Education, 45, 768–776. https://doi.org/10.1111/j.1365-2923.2011.04026

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cul- tural competence: A critical distinction in defining physician train- ing outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117–125. https://doi.org/10.1353/hpu. 2010.0233.

U.S. Department of Health and Human Services (2017). National Healthcare Quality and Disparities Reports. Content last reviewed April 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/research/findings/nhqrdr/index.html

Publisher’s Note Springer Nature remains neutral with regard to juris- dictional claims in published maps and institutional affiliations.

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

Behav Analysis Practice (2016) 9:84–94 DOI 10.1007/s40617-016-0111-6

DISCUSSION AND REVIEW PAPER

Developing the Cultural Awareness Skills of Behavior Analysts

Elizabeth Hughes Fong1 & Robyn M. Catagnus2 & Matthew T. Brodhead3 &

Shawn Quigley4 & Sean Field5

Published online: 4 February 2016 # Association for Behavior Analysis International 2016

Abstract All individuals are a part of at least one culture. These cultural contingencies shape behavior, behavior that may or may not be acceptable or familiar to behavior analysts from another culture. To better serve individuals, assessments and interventions should be selected with a consideration of cultural factors, including cultural preferences and norms. The purpose of this paper is to provide suggestions to serve as a starting point for developing behavior analysts’ cultural awareness skills. We present strategies for understanding be- havior analysts’ personal cultural values and contingencies and those of their clients, integrating cultural awareness practices into service delivery, supervision, and professional development, and becoming culturally aware in everyday practice.

Keywords Culture . Cultural awareness . Applied behavior analysis . Diversity

Skinner (1953) defined culture as variables Barranged by other people^ (p. 419). That is, humans control contingencies of

Elizabeth Hughes Fong, Robyn M. Catagnus, and Matthew T. Brodhead shared first author

* Robyn M. Catagnus [email protected]

1 Arcadia University, Glenside, PA, USA 2 The Chicago School of Professional Psychology, Chicago, IL, USA 3 Purdue University, West Lafayette, IN, USA 4 The University of New Mexico Medical Group, Albuquerque, NM,

USA 5 Western Michigan University, Kalamazoo, MI, USA

reinforcement and punishment that affect the behavior and learned reinforcers and punishers of a person or a group of people. Culture may be further defined as Bthe extent to which a group of individuals engage in overt and verbal behavior reflecting shared behavioral learning histories, serving to dif- ferentiate the group from other groups, and predicting how individuals within the group act in specific setting conditions^ (Sugai et al. 2012, p. 200). Distinguishable stimuli and re- sponse classes that occur in cultures include race, socioeco- nomic class, age, religion, sexual orientation, ethnicity, dis- ability, nationality, and geographic context (Sugai et al. 2012). An individual’s unique set of distinguishable stimuli and response classes are collectively referred to as an individ- ual’s cultural identity. One benefit of determining cultural identity is it can allow behavior analysts to develop an aware- ness of a client’s personal cultural values, preferences (i.e., learned reinforcers), characteristics, and circumstances (contingencies at the third level of selection; Skinner 1981). There are possible benefits for society, too, such as to better guide assessment and intervention practices. By acknowledg- ing the importance of culture, behavior analysts can help achieve socially meaningful goals such as reducing disparities in access to services and improving the quality of services for diverse populations in behavioral health systems (U.S. Department of Health and Human Services 2001).

Culturally aware behavior analysts should understand their own cultural values, preferences, characteristics, and circumstances and seek to learn about those of their clients. That is, behavior analysts should be aware about their own personal biases and how they compare to and may affect their relationship with their client. This awareness of both self and clients may be important because, as Spring (2007) suggests, evidence-based services require a combination of clinical ex- pertise and knowledge of the client’s preferences and learning histories. Behaviorally, cultural awareness may be defined as

85 Behav Analysis Practice (2016) 9:84–94

the discriminated operant of tacting contingencies of rein- forcement and punishment administered by a group of indi- viduals. In other words, a behavior analyst who is culturally aware is able to identify the reinforcement and punishment contingencies that have been established by themselves, their colleagues, their family, and any other social group they may belong to or identify with. Behavior analysts’ ability to tact contingencies for self and others may facilitate development of a behavior change program that is informed by their clients’ specific cultural contingencies.

Further, cultural awareness may be important because be- havioral patterns that are viewed as problematic in our own culture may be the norm in other cultures (Goldiamond 2002; Vandenberghe 2008). Consider the following example of a child who was referred for a functional assessment for Bwithdrawn^ behavior. The behavior analyst and a special education observed the student became Bwithdrawn^ after re- ceiving verbal praise. In fact, the student ultimately stopped engaging in any appropriate behavior which lead to the verbal praise. While collaborating with the family to gather data dur- ing the functional assessment, they determined that the stu- dent’s Bwithdrawn^ behavior occurred because of child’s lack of comfort with receiving individual attention. In the child’s culture, the whole (i.e., community) comes before the individ- ual. However, neither the behavior analyst nor the special education teacher questioned their personal assumption that the behavior is inappropriate for the classroom or their prefer- ences about how children should act after receiving praise. Because the student’s withdrawn behavior is maintained by a lack of attention, the behavior analyst and special education teacher suggest administering praise privately. In this case, their lack of understanding about how the cultural contingen- cies support the client’s Binappropriate behavior^ may have resulted in a treatment recommendation that was incongruent with cultural values. However, a culturally aware intervention, which seeks understanding of client values, characteristics, preferences, and circumstances would honor the client’s cul- ture and allow the client to successful in a given environment.

A thorough behavior analytic intervention may be effective with individuals across various cultures (Kauffman et al. 2008; Tanaka-Matsumi et al. 1996). However, skilled, thorough, and well-trained behavior analysts may not always consider client culture. When assessing an individual’s or a group’s behavior, behavior analysts often collect data about motivating opera- tions, antecedents, behaviors, and consequences. However, common functional assessment data collection strategies and interview forms may not thoroughly explore cultural prefer- ences and norms. Behavior analysts may consider the intersec- tion of a cultural and linguistic context with the terms, concepts, and science of behavior analysis (Jones andHoerger 2009). It is possible that, without information about cultural preferences and norms, behavior analysts may unintentionally provide less than optimal service delivery.

Consider an example of a behavior analyst who provided in-home and community services to the family of a child with severe autism. The family, to whom church is very important, attended a weekly three hour church service. The behavior analyst, who did not attend church and was not a religious person, failed to inquire in detail about the family’s and child’s experience at church. Eventually, the family specifically asked the behavior analyst to teach the child the necessary skills to participate in the church service. However, the behavior ana- lyst still did not assign a high priority to teaching the child the skills needed for successful church attendance. The behavior analyst’s choices demonstrated a lack of understanding of the client’s values, characteristics, preferences, and circum- stances. In contrast, a culturally aware behavior analyst may be aware that Bthe selection of target behaviors is an expres- sion of values^ (Kauffman et al. 2008, p. 254) and that paren- tal expectations of children are likely controlled by cultural contingencies (Akcinar and Baydar 2014).

In addition to the previous two examples, being culturally aware may also increase the probability that behavior analysts will engage in behaviors that are socially acceptable to people from diverse cultural backgrounds. These behaviors include selecting culturally appropriate treatments (see Rispoli et al. 2011), recognizing that Bparenting styles that are culture spe- cific could lead to distinct behavioral consequences for a child^ (Akcinar and Baydar 2014, p. 119), and implementing culturally appropriate language acquisition programs (see Brodhead et al. 2014). Cultural awareness could also ensure that behavior analysts treat service delivery as Balways a two- way street^ (Bolling 2002), meaning that the relationship be- tween the behavior analyst and the stakeholders should in- clude input about what cultural contingencies and values may contribute to an effective relationship and intervention.

Finally, increasing cultural awareness may also decrease the probability of behavior analysts expecting the clients they serve to conform to their own cultural and scientific values and contingencies. The science of applied behavior analysis (ABA) is a unique cultural system (see Glenn 1993). Given that the science of ABA inherently embodies a certain set of values such as aWesternizedmodel of science and health care, the cultural values and contingencies of ABA may not always align with those of the client. As Bolling (2002) noted,

It is difficult for people in the US cultural mainstream, including researchers, to believe that there are any assump- tions other than their own about how the world works, what a ‘person’ is, howwe function, how timeworks, what feelings are, how to use language, what the goal of life is, how people interrelate, [and] how and where it is appro- priate to show feelings or to seek help. (p. 22)

Awareness of cultural differences and similarities may al- low for programmatic modifications that result in more

86 Behav Analysis Practice (2016) 9:84–94

culturally appropriate models of behavior analytic service delivery.

In summary, there may be many important reasons for be- havior analysts to develop cultural awareness skills.

Although there is a growing interest in conceptual (e.g., Brodhead et al. 2014; Fong and Tanaka 2013) and applied strategies for administering behavioral interventions for cli- ents from diverse cultural backgrounds (e.g., Padilla Dalamau et al. 2011; Rispoli et al. 2011; Washio and Houmanfar 2007), there is little guidance concerning how practicing behavior analysts can become culturally aware or further develop that awareness. Therefore, guidance on how to become culturally aware may be an important resource for behavior analysts.

The purpose of this paper is to offer suggestions that can serve as a starting point for how behavior analysts may further increase their cultural awareness. We believe that cultural awareness, as described herein, reflect Baer et al. (1968) state- ment that the Bbehavior, stimuli and/or organism under study are chosen because of their importance to man and society^ (p. 92). Individuals participating in behavior change programs and those who provide significant support for them should determine what is important to them, to their society, and to their culture. In this paper, we discuss strategies for under- standing a client’s cultural values and contingencies, as well as those of the behavior analyst. Then, we describe strategies for embedding cultural awareness practices into behavior an- alytic service delivery, supervision, and professional develop- ment. Finally, we conclude with additional discussion and considerations for becoming culturally aware in everyday practice.

Strategies for Developing Cultural Awareness

The following two sections describe how behavior analysts can become more aware of personal cultural values and con- tingencies and how they can develop skills to learn about their clients’ cultural identities. We will refer to cultural values and contingencies as the cultural system, except where values or contingencies play an independent role in our analysis of de- veloping cultural awareness. We will refer to cultural identity as characteristics that extend beyond individual differences to those traits that members of a given culture share with one another (Adler 1998). For example, an individual from Africa may express their cultural identity through their belief struc- ture, attire, foods eaten, or hair style. Even though this indi- vidual might identify as African, there are subcultures to which they might further identify with. Our suggestions are meant to serve as a starting point for furthering a behavior analytic understanding of cultural awareness and how that awareness can be integrated and improved upon in everyday practice. It is recommended that behavior analysts

concurrently engage in cultural awareness practices concerning their own behavior as well as those of their clients. It is important to be aware of one’s own biases or preconceived notions as a behavior analyst, as well acknowl- edging limitations in one’s cultural knowledge. Lastly, our suggestions are not intended to result in a rigid set of rules or practices. Rather, our hope is the suggestions will lead to broad practices that develop and continually refine cultural awareness, which will hopefully allow behavior analysts to be more open and flexible to the various cultures that will be experienced. Openness and flexibility in the presence of var- ious cultures will hopefully result in better outcomes for those we serve.

Developing Cultural Awareness of Self

From a behavior analytic perspective, self-awareness can be defined as verbal discrimination of our own behavior (Barnes- Holmes et al. 2001). Sugai et al. (2012) describe culture as common behaviors related by comparable learning histories, social and environmental contingencies, contexts and stimuli, so self-awareness might also include verbal discrimination of these aspects of personal experience. An understanding of our own cultural system may be an important first step toward correcting biases that affect our interactions with others (Lillis and Hayes 2007). The American Psychological Association’s (APA) (2003) multicultural guidelines encour- age clinicians to Brecognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are eth- nically and racially different from themselves^ (p. 382). Developing self-awareness may prevent our biases from im- peding how we serve culturally diverse clients.

One strategy to enhance cultural self-awareness is talking about our diverse client interactions with a professional com- munity in group discussions, written forums, journals, men- torship meetings, verbal feedback sessions, or self-reflective exercises (Tervalon andMurray-Garcia 1998). Skinner (1974) emphasized the relationship between self-awareness and con- trol over our own behavior,and proposed that talking about our behavior is how we achieve self-awareness. Recent be- havior analytic research indicates that when individuals ver- bally describe their own behavior, the behavior may change (Tourinho 2006). Discussion with mentors and colleagues may help behavior analysts learn about themselves and also change their cross-cultural interactions for the better.

Another suggestion is to be Bmindful^ by attending fully and alertly, in the moment, to client interactions and our own private events, without judging or evaluating the events as they occur (Bishop et al. 2004; Hayes and Plumb 2007; Vandenberghe 2008). We recommend practitioners hone their ability to attend closely to clients and self, in context, for two reasons related to self-awareness. First, such attention may

87 Behav Analysis Practice (2016) 9:84–94

help enhance skills of self-observation and self-description regarding our overt and covert behavior. Also, while we can remain committed to overtly behaving in ways consistent with values of multiculturalism, even in the presence of values and contingencies that create bias, mindfulness may reduce the biases that produce thoughts, feelings, and reactions to cultur- ally diverse people (Lillis and Hayes 2007). Attending closely to our clients and being active and alert is good practice for building rapport, too.

Clinicians can engage in more culturally aware practice by assessing, collecting data, and testing hypotheses rather than accepting their own experiences and biases as the norm (Sue 1998). Scientific mindedness is a characteristic of clinicians and human service providers who develop theories about cli- ent behaviors by analyzing data rather than by dependence on their personal assumptions (Sue 1998), and may reduce bias and foster better understanding of client behavior. A reliance on scientific, behavior analytic knowledge when workingwith clients is also required by the Professional and Ethical Compliance Code for Behavior Analysts (BACB 2015).

While mindful attention focuses on the interaction between the behavior analyst and the client/family, scientific minded- ness is a focus on interpreting information from the client and family; both characteristics facilitate culturally aware practice. For example, a behavior analyst consults to a family of a child with a sleep disorder, and learns that the mother sleeps in her five-year-old child’s bed while the father sleeps in a larger room, alone. The practitioner may notice, and be able to co- vertly tact, that this is not the norm of the cultural majority nor congruent with his personal experience or values. The analyst may assume that the mother should not sleep in the child’s bed or notice thoughts of judgment he feels. Lillis and Hayes (2007) recommend practitioners accept that such reactions may be normal, given our cultural systems and the human tendency to evaluate, but remain committed to acting positive- ly based on our values. Through a process of assessment and covert verbal behavior, the practitioner might accept the co- sleeping arrangement to be culturally appropriate for and pre- ferred by the family, and choose to develop an intervention that keeps the arrangement in place. A blend of both self- awareness and reliance on scientific knowledge is likely to produce the most culturally aware assessment and intervention.

Finally, there are several self-assessment tools that behav- ior analysts can use to become more aware of their own cul- tural identity. We recommend the use of assessment tools for measuring and reflecting on the clinician’s own cultural biases, values, and understanding. One assessment tool, the BDiversity Self-Assessment,^ that can be utilized during the intake process allows team members to examine their under- standing of diversity (Montgomery 2001); this tool asks users to reflect on their own assumptions and biases by answering 11 questions. Another assessment tool that may be useful is

the self-test questionnaire entitled BHow Do You Relate to Various Groups of People in Society?^ (Randall-David 1989). This questionnaire asks respondents how they might respond to individuals of various cultural backgrounds—by greeting, by accepting, by obtaining help from, by having background knowledge about, and/or by advocating for the individuals. The 30 types of individuals in these questions are then organized into five categories: ethnic/racial, social issues/ problems, religious, physically/mentally handicapped, and political, and a concentration of checks within a specific cat- egory of individuals or at specific levels of response may then indicate a conflict that could prevent the respondent from pro- viding effective treatment. Behavior analysts can then consid- er how their biases might affect treatment and may consider other courses of action, such as making referrals to other be- havior analysts. A final potentially useful measure is the Multicultural Sensitivity Scale (Jibaja et al. 2000), a 21-item self-assessment tool developed as a valid and reliable way to measure multicultural sensitivity. This tool was originally used to assess the multicultural sensitivity of teachers and was later adapted to be used by physician assistant students (Jibaja-Rusth et al. 1994). Altogether, the behavior analyst may find these assessments helpful in further developing their own cultural awareness in order to further develop culturally competent methods of service delivery.

Developing Cultural Awareness of Clients

The above section describes strategies for how a behavior analyst may learn about his or her own cultural system. Below, we describe how behavior analysts may learn more about their client’s cultural system through assessment prac- tices. Culturally aware assessment practices may allow behav- ior analysts to obtain important cultural information about clients in order to understand their worldviews. Culturally aware assessment may also allow behavior analysts to identify any potential cultural barriers such as modalities of commu- nication and expression of emotions (see Garcia et al. 2003).

To increase the probability that assessment will identify cultural variables, Vandenberghe (2008) recommends focus- ing on functional relations and behavioral principles rather than topography. For example, Filipino families often live with extended family members, and the household situation can seem chaotic by Western living standards. If a child has difficulty sleeping, a behavior analyst may advise the parents that they should separate the sleeping room from the living room. People of Filipino descent may be shy about responding to someone in a position of authority, so they may say Byes^ to the behavior analyst. However, during the following session, it might be revealed that the parents did not change anything and that the child is still sleep deprived. In this case, a natural reaction may be to become frustrated with the lack of parental follow through. However, lack of follow through may also be

88 Behav Analysis Practice (2016) 9:84–94

interpreted as an indicator that the intervention recommenda- tion may not have been culturally appropriate.

Vandenberghe’s (2008) description of functional analytic psychotherapy may also be a useful resource for determining how to provide culturally aware behavior analytic practices. Vandenberghe (2008) emphasizes the need for a behavior ana- lyst to be aware of differences that may exist, including cultural differences, between the behavior analyst, client, and their fam- ilies. Specifically, behavior analysts should be knowledgeable about the client’s culture, differentiate between an unfamiliar cultural norm and a pathology, and take culture into consideration during the therapeutic process. Finally, Hymes (1962) noted that communicative competence is related to an individual’s awareness of the laws of language structure and language use within a given culture. Therefore, behavior ana- lysts should be skilled in sending and receiving cultural com- munications. Specific recommendations are described below.

Recommendations

Consider the Language of Assessment Our first recommen- dation, which applies to all phases of assessment and treat- ment, is that behavior analysts should reflect on the spoken and written language he or she uses and how it will be per- ceived by the client. We recommend behavior analysts avoid the use of behavior analytic jargon, as it may confuse clients and their families, and possibly lead to their failure to imple- ment interventions. This recommendation is consistent with the Professional and Ethical Compliance Code for Behavior Analysts (2015). For example when the phrase Bfunctional analysis^ is used, Japanese families assume that it is mathe- matical jargon rather than a reference to a behavior analytic assessment process. Avoidance of excessive or complex be- havior analytic jargon may eliminate such problems.

It is important throughout assessment and treatment to communicate in a manner easily understood, culturally aware, and does not include terms that are culturally inappropriate or confusing (Rolider andAxelrod 2005). Furthermore, it may be important to consider who will be completing service related forms (e.g., intake paperwork) and whether the level of liter- acy and comprehension of the language used in the forms are similar. If a person lacks adequate language comprehension, completing paperwork may be difficult, embarrassing, or in- timidating. In such a case, behavior analysts may consider giving the person the opportunity to complete the forms orally or have another person help with the form completion. They may also consider using an interpreter or providing forms in the person’s native language. Additionally, we agree with Vandenberghe’s (2008) recommendation that the language used to define problem behaviors should be carefully exam- ined to ensure the behaviors are communicated in a positive manner using multiple forms of communication that are sen- sitive to potential cultural differences in eye contact, wait time,

meanings of words, non-vocal body language, personal space, and quality of voice.

Understand Cultural Identity Our second recommendation is to consider that the client, and the client’s family and com- munity, are important sources for acquiring an understanding the cultural identity of the individual. Therefore, we recom- mend conducting an analysis of cultural identity with stake- holders immediately after service initiation with the client and/ or family. The cultural identity analysis should inform the assessment process and the designing of interventions. During intake, the behavior analyst may, with proper consent, gather input from key community members familiar with the client, in addition to those whose feedback is typically sought (e.g., teachers, professionals, administrators, and family). Additionally, the behavior analyst should seek recommenda- tions from the family regarding additional parties (e.g., other community members) who should be involved. Family and community members may be able to provide the most valu- able information regarding the client’s culture, language, and sociocultural framework (Salend and Taylor 2002). These dis- cussions will allow members of the team to acquire a mutual understanding of the client’s cultural system, which may result in increased cultural awareness.

It is important to highlight that the client/family’s language is an important cultural variable that should be understood in addition to collaboration with stakeholders. For example, be- havioral patterns may be similar across cultures, while the language and concepts that are used can differ (Vandenberghe 2008). In Japan, parents and teachers may use the word Bpanic^ to describe a child’s behavior, and this may imply a Btantrum^ or Bmeltdown.^ Because the word Btantrum^ is often associated with baby colic behavior, par- ents and teachers may prefer to use Bpanic^ to describe the aggressive behavior of older children.Without knowing this, a behavior analyst may initially misunderstand what the client’s challenging behavior is. It is therefore important for behavior analysts to clarify what the client or family actually mean by the terms they use.

The behavior analyst should also consider accounting for what treatments are appropriate, preferable, or considered norms within a culture. As illustrated by the example of the Filipino family at the beginning of this section, identifying cultural norms may be important for successful assessment and effective treatment. Information about what is acceptable within a person’s culture is also ideally obtained beginning with the intake process (and later during the assessment pro- cess) by including stakeholders in the process and ensuring that background information includes input from multiple sources of information (assessments and interviews; Sugai et al. 2012). For example, the grandparents rather than the parents may be the primary caregivers in an Indian family. Therefore, it would be important to include the grandparents

89 Behav Analysis Practice (2016) 9:84–94

during intake in order to obtain information. During later phases of the intervention, it may also be beneficial to contin- ue to involve the family in development of the data collection and to make changes in the intervention based on the family’s interactional style. In designing the intervention, the team will then be able to include culturally appropriate reinforcers and skill building, again taking into account strategies that are appropriate to the client’s culture and belief system.

It may also be important to define a client’s behavior in positive terms and in relation to cultural norms to help ensure culturally aware behavioral definitions. For example, in exam- ining table manners across cultures, French parents may be- lieve that child table manners are the essence of their culture. In Japan, in contrast, many children will leave the table during a meal, and it is acceptable in certain settings for them to run around, even in restaurants. More specifically, during lunch with family friends, a Japanese child might imitate a peer and leave the table during lunch with a smile on his or her face. For Japanese parents, this is the cultural norm, but French parents often consider this behavior is inappropriate.

Use Readily Available Resources Our third and final recommendation for this section is for behavior analysts to consider making use of the resources that are already available to help make their practice more culturally aware. Salend and Taylor (2002) describe guidelines for creating more culturally aware functional behavior assessments. These guidelines suggest behavior analysts should involve family, community members, and professionals to learn about the client’s culture and examine possible sociocultural explanations of behavior. They also sug- gest behavior analysts attend trainings and engage in activities that allow them to reflect on how their culture might impact their belief system (Salend and Taylor 2002).

Another resource that can help behavior analysts en- hance their culturally awareness is provided by Sugai et al. (2012). The authors discuss how applied behavior analytical terms can be understood within different cultural contexts. For example, in some cultures, the concept of reinforcement can be illustrated by describing the act of bowing to greet one another. In this exchange, a bow is more likely to be given if a person is first bowed to, thus the initial bowing behavior is reinforced. Like Salend and Taylor (2002), these authors describe how steps in inter- ventions, such as school-wide positive behavior support, can be made more culturally aware—for example, by using activities that are considerate of learning histories and the norms and values of the culture, family, school, and community.

Tanaka-Matsumi et al. (1996) also provided another re- source for increasing culturally aware behavior analytic ser- vices. Specifically, the authors provide guidelines for conducting a culturally informed functional assessment inter- view, in which increases in accurate case formulation,

decreases in diagnostic errors, decreases in attrition, increases in the credibility of the therapy, and increases in the expecta- tion of positive change, client compliance, and active partici- pation in treatment might be a result. The authors emphasize the importance of examining the functional relationships be- tween a client’s behavior and culture, which may increase buy-in from all parties involved and help acquire an accurate description of the client’s challenging behavior.

Moving from Assessment to Treatment Once information has been obtained through reflection on and assessment of the client’s culture as well as the behavior analyst’s own culture, the behavior analyst can use the information to make informed decisions about next courses of action, such as accepting the client, referring the client elsewhere, seeking additional infor- mation about the client’s culture, or securing supervision from a more experienced behavior analyst as needed. It should be noted that lack of a cultural match does not necessarily mean that the behavior analyst cannot provide adequate services to the client. A behavior analyst should rely on professional ex- perience and knowledge to serve this client, given the behav- ior analyst’s cultural context, but should also remember that within-group differences are greater than between-group dif- ferences (Sue 2003). For example, a client of the same race and socioeconomic background may not have cultural norms that are strongly similar to those of the behavior analyst. There are various domains of culture (e.g., family, geography, sexual orientation, and religion) that relate to the behavior of the individual. A behavior analyst who lacks experience and knowledge to serve a culturally different client should seek additional information about the client’s cultural behaviors, values, and norms and should also seek direct exposure to culturally similar experiences and people, if possible (Sugai et al. 2012; Vandenberghe 2008). Finally, even when behavior analysts strive to be more culturally aware, provision of cul- turally aware services may not always go smoothly (Vandenberghe 2008), so behavior analysts should view skill development in this domain as a process and engage in ongo- ing assessment to continually improve their practice (see the BCultural Awareness Training in Graduate and Professional Development Programs^ section below).

Recommendations for Increasing Cultural Awareness within Clinical Organizations and Professional Development Programs

In order for behavior analysts to become aware of the cultural values of their clients, as well as their own cultural values, service delivery and training programs must also develop sys- tems of support and encourage professional growth in this area. The following recommendations concern how cultural awareness training can be integrated into clinical

90 Behav Analysis Practice (2016) 9:84–94

organizations and graduate and professional development pro- grams. These recommendations are not all inclusive; rather, they highlight examples of how behavior analysts can institu- tionalize cultural awareness within their professional and training systems.

Increasing Cultural Awareness within a Clinical Organization

One strategy to increase the likelihood of culturally aware behavior is to embed cultural awareness training and supervi- sion at the institutional level within an organization. Implementing training and supervision systems may help an organization achieve the goal of institutionalizing the skill of cultural awareness (see Betancourt et al. 2003, for suggestions on cultural competency training for health care workers). The following three recommendations are based on Brodhead and Higbee’s (2012) recommendations for using behavioral sys- tems to teach andmaintain ethical behavior in a human service organization.

The first recommendation is to identify an individual with- in the organization who can be charged with ensuring that cultural awareness is addressed. Because it is likely not to be reasonable or possible for all members of the organization to focus solely on developing cultural competency, it may be useful for an organization to identify one individual who can help guide the development of cultural awareness in other members of the organization. This individual’s role would be similar to that of the ethics coordinator described by Brodhead and Higbee (2012). The identified individual who would focus on cultural competency would also be responsi- ble for identifying points of discussion for individual and group supervision and would also serve as a reference within the organization to stay up-to-date on best practices for cul- tural competency.

The second recommendation is to incorporate cultural awareness training into individual supervision. During indi- vidual supervision, the supervisor can ask the supervisee to discuss any instances where conflicts between cultures might result in barriers to effective service delivery. For example, a supervisee may seek feedback on the appropriate way to re- spond when offered food during in-home consultation. The supervisee may also seek guidance on how the cultural values and contingencies of a specific family should be considered when designing a parent training, as parental values might lead to parenting styles that are culture specific (Akcinar and Baydar 2014). The purpose of discussing cultural awareness during supervision meetings is to provide multiple, continu- ous opportunities for feedback and discussion. It is recom- mended that fidelity checklists be developed and used in su- pervision include items that assess cultural awareness during assessment, intervention, and ongoing consultation.

The third recommendation is to incorporate cultural aware- ness training into group supervision and training. Similar to company-wide trainings on ethics, functional assessment, and skill acquisition, trainings on cultural competency can allow for group discussion and feedback on best practices for the cultures the organization is likely to serve. Difficult or impor- tant questions that arise during individual supervision can be addressed during group training, allowing for additional op- portunities for discussion and feedback about the appropriate service delivery under a given set of cultural variables. Discussions can be facilitated by a company expert in cultural competency to ensure that topics are adequately addressed (see Wolfe and Durán 2013, for a review and suggestions for a similar training in a public school setting).

One strategy for behavior analysts to document the efficacy of their services may be to distribute social validity surveys to the clients they serve. Social validity surveys can ask whether clients are pleased with their interactions with the behavior analyst, whether the behavior analyst is respectful of cultural values, and whether the behavior analyst recommends cultur- ally appropriate interventions. Such a survey could also be useful for evaluating the effectiveness of supervision and pro- fessional development programs in creating culturally aware behavior analysts.

Cultural Awareness Training in Graduate and Professional Development Programs

Developing training programs for behavior analysts that teach cultural awareness could have a positive impact on the field of behavior analysis. This is especially important given the re- cent expansion of behavior analysis training programs as well as the application of behavior analysis outside of the United States. To address the need to develop cultural awareness skills, behavior analysts will need to develop coursework spe- cific to cultural awareness, develop standards for practice and competency (Carey and Marques 2007; Diaz-Lazaro and Cohen 2001; Fong and Tanaka 2013; Westefeld and Rasmussen 2013), and develop continuing education oppor- tunities to assure continued competency (Cross et al. 1989).

One strategy to ensure that the professional development of behavior analysts addresses cultural awareness is to include cultural awareness content in behavior analytic course se- quences. The BACB Fourth Edition Task List does not explic- itly cover cultural awareness or content related to cultural systems. However, other comparable fields such as psycholo- gy and medicine require specific training for cultural aware- ness (American Psychological Association [APA], 2015; Association of American Medical Colleges 2005). Specifically, medical students are required to have cultural competency training integrated into their curriculum in order to assure that cultural competency is established as an impor- tant and pervasive issue in the provision of care. Furthermore,

91 Behav Analysis Practice (2016) 9:84–94

there exist specific accreditation standards in psychology re- lating to cultural competency in the practice of psychologists that concern the various means by which cultural competency can impact the conduct of the behavior analyst (APA 2015). In addition to ethical standards regarding the practice of behavior analysis, we recommend that the field adopt appropriate cul- tural training standards. While it may be the case that effective assessment and intervention will likely include an analysis of relevant cultural variables, the absence of training standards related to conducting and developing culturally aware practice skills in our discipline’s task list (BACB 2015) may lead to a failure to foster and develop the necessary skills. Specifically, these training targets would be of the greatest importance in BRecommendations for Increasing Culture of Awareness within Clinical Organizations and Professional Development Programs^ Section of the task list, which focuses on the de- velopment of skills related to the client-centered responsibili- ties of aspiring behavior analysts.

Another strategy to increase cultural awareness may be to institutionalize standards of practice for serving clients from diverse cultural backgrounds. Representing the Multicultural Alliance of Behavior Analysis, a special interest group of the Association for Behavior Analysis International, Fong and Tanaka (2013) published a list of seven standards for cultural competence in behavior analysis. These standards include un- derstanding one’s own cultural biases and how these might conflict with the biases of those they serve, using culturally aware applications of behavior analysis, and advocating for diversity in the workplace. Fong and Tanaka (2013) also sug- gest that behavior analysts advocate for culturally appropriate language interventions, participate in continuing education and training related to cultural awareness, and make appropri- ate referrals if they are not qualified to work with diverse clients. We encourage organizations and training programs to review Fong and Tanaka’s (2013) recommendations and consider integrating them into supervision and coursework.

Researchers, creators of training materials, and administra- tors of university programs can all contribute to developing cultural awareness skills in the field. We encourage more re- search on topics of diversity, cross-cultural implementation, and international dissemination of ABA. It has been recom- mended that when behaviorally oriented researchers publish articles, the BParticipant^ section include more information about cultural variables (Brodhead et al. 2014; Kaufman et al. 2008). We further suggest that authors of textbooks and training manuals, and designers of continuing education and online trainings increase the number and variety of topics related to culture and diversity. By adding more examples of scenarios involving issues of diversity, cultural awareness, and culturally aware assessment and intervention, behavior ana- lysts may continue to lay the groundwork for pre-service be- havior analysts to practice more effectively with a broader range of populations. Administrators and faculty in

universities can set specific learning outcomes for teaching about diversity and cross-cultural implementation skills. Such initiatives can be adopted at the level of the university or within an academic department. Behavior analytic training programs can also develop student abroad experiences to in- troduce students to different cultures or program experiences involving different local cultures. Effectiveness with diverse populations can be specified as both a value and a learning outcome for students in our programs.

A final strategy for integrating cultural awareness into pro- fessional development is to encourage continuing education requirements for cultural awareness. In the field of behavior analysis, professional development with respect to cultural awareness receives no special attention. As a result, if behav- ior analysts in the field come into contact with issues related to culture in continuing education, they are likely to do so in the general category of ethics. Even if standards for cultural awareness are not established, we recommend that qualified behavior analysts consider conducting continuing education trainings on cultural awareness in order to increase the prob- ability of behavior analysts coming into contact with impor- tant information related to cultural systems.

Discussion

Two decades ago, Hayes and Toarmino (1995) asked, Bif be- havioral principles are generally applicable, why is it neces- sary to understand cultural diversity?^ Today, behavior ana- lysts may remain unconvinced that specific training in cultural awareness is required. The BACB Fourth Edition Task List does not directly address cultural awareness in its own titled guideline, and most behavior analytic graduate and certificate programs are based in large part on the Task List (BACB 2012). We argue that few specific practice guidelines are available to behavior analysts. However, the Professional and Ethical Compliance Code for Behavior Analysts (BACB 2015) does touch on this topic, with the requirement that

Where differences of age, gender, race, culture, ethnic- ity, national origin, religion, sexual orientation, disabil- ity, language, or socioeconomic status significantly af- fect behavior analysts’ work concerning particular indi- viduals or groups, behavior analysts obtain the training, experience, consultation, and/or supervision necessary to ensure the competence of their services, or they make appropriate referrals. (p.5)

However, we suggest that such cultural differences always affect our work with individuals or groups. Therefore, it may be important for behavior analysts to continue to develop their cultural awareness skills by systematically ensuring ongoing

92 Behav Analysis Practice (2016) 9:84–94

training, experience, and supervision for cultural competence and awareness.

The above recommendations are meant to serve as a starting point for considering strategies to increase cultural awareness among behavior analysts. Although the recommendations may very well improve a behavior analyst’s cultural awareness, there are several additional considerations and limitations to our rec- ommendations. First, it is important for behavior analysts to not make gross generalizations about clients or their families based on the culture(s) they represent. Specifically, if an individual lives in the United States of America, is light skinned, attends a Christian denomination church and speaks English fluently, one should not assume that the individual is of European American descent. In fact, that individual might be of Hispanic descent, speak Portuguese fluently, come from Guatemala, and reside in the United States temporarily while competing higher education requirements. It is very possible that avoiding such generalization or stereotyping can be difficult when learning or teaching about cultural practices as part of a cultural awareness system. However, collecting information about different cultural systems should place behavior analysts in a better position to Binfer the possible effects of the environment^ in order to make effective treatment recommendations (Brodhead et al. 2014, p. 81). Therefore, we encourage behavior analysts consider our recommendations for increasing culturally awareness prior to the intake process.

Another limitation of this paper is that it does not provide systematic guidelines for how behavior analysts should work with culturally diverse clients. However, because there is a lack of resources in the area of cultural awareness and behav- ior analysis, we hope this paper serves as a starting point for future discussions and analyses. Systematic guidelines for practicing behavior analysts have been published in other areas, such as guidelines for identifying an appropriate function-based treatment for escape-maintained problem be- havior (Geiger et al. 2010) and for maintaining professional relationships (Brodhead 2015). Therefore, it may be useful for future researchers or behavior analysts to develop systematic guidelines for working with culturally diverse clients in order to provide practicing behavior analysts with a systematic framework for their work.

Finally, it is important to note that the fidelity of the behav- ior analytic intervention should not be compromised in order to incorporate culturally aware practices. It is very possible that a culturally informed assessment may lead to a culturally informed intervention that may ultimately lead to implemen- tation with high fidelity. Whereas, an assessment that is not culturally informed may lead to an intervention not matched to client culture which then can’t implemented with fidelity. In some cases, however, multiple courses of treatment may be available to deliver the same treatment outcome. If this occurs, we recommend that behavior analysts consider identifying the most culturally appropriate treatment whenever possible. See

Padilla Dalamau et al. (2011) for an example of identifying client preferences for functional communication training interventions.

In summary, cultural variables matter even when implementing practices supported by research and based on the science of behavior analysis (Sugai et al. 2012). No be- havior analyst can learn everything about every culture. However, we can develop skills to collect the right data and to understand ways in which culture may affect reinforcers, goals, teams, and interventions in general. We can cultivate awareness of diversity and willingness to honor what is right for our clients. Behavior analysts may not be even aware of how much our personal learning histories differ from the con- tingencies related to our clients’ behaviors, their reinforcers, their behavioral patterns, and the effect of the societal systems in which they live. Continuing to cultivate openness to learn- ing about these variables, along with an awareness of the limitations created by our personal learning histories, may lead us in new directions that will benefit diverse populations with behavior analysis. The growing diversity of our popula- tion expands the complexity and variety we can expect to encounter, and so we must continue to develop cultural com- petence skills through behaviors of awareness, collecting the right data, and honoring what is important to our clients.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no competing interests.

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

References

Adler, P. S. (1998). Beyond cultural identity: reflections on multicultur- alism. Basic concepts of intercultural communication: Selected read- ings, 225–245.

Akcinar, B., & Baydar, N. (2014). Parental control is not unconditionally detrimental for externalizing behaviors in early childhood. International Journal of Behavioral Disorders, 38, 118–127. doi: 10.1177/0165025413513701.

American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58(5), 377–402. doi:10. 1037/0003-066X.58.5.377.

American Psychological Association. (2015). Guidelines and principles for accreditation of programs in professional psychology: Quick reference guide to internship programs. Retrieved from http:// www.apa.org/ed/accreditation/about/policies/interns.aspx.

Association of American Medical Colleges. (2005). Cultural Competence Education. Retrieved from http://www.aamc.org/download/54338/ data/culturalcomped.pdfBaer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis.

93 Behav Analysis Practice (2016) 9:84–94

Journal of Applied Behavior Analysis, 1(1), 91–97. doi: 10.1901/ jaba.1968.1-91.

Barnes-Holmes, Y., Barnes-Holmes, D., Roche, B., & Smeets, P. M. (2001). The development of self and perspective-taking. Behavioral Development Bulletin, 1, 42–45.

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimen- sions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97.

Behavior Analyst Certification Board. (2012). Fourth edition task list, retrieved from http://bacb.com/wp-content/uploads/2015/05/ BACB_Fourth_Edition_Task_List.pdf.

Behavior Analyst Certification Board. (2015). Guidelines for responsible conduct for behavior analysts. Retrieved from http://bacb.com/wp- content/uploads/2015/08/150824-compliance-code-english.pdf.

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O., II. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293–302.

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z. V., Abby, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: a proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230–241. doi:10. 1093/clipsy/bph077.

Bolling, M. Y. (2002). Research and representation: a conundrum for behavior analysts. Behavior and Social Issues, 12, 19–28.

Brodhead, M. T. (2015). Maintaining professional relationships in an interdisciplinary setting: strategies for navigating nonbehavioral treatment recommendations for individuals with autism. Behavior Analysis in Practice, 8, 70–78. doi:10.1007/s40617-015-0042-7.

Brodhead, M. T., & Higbee, T. S. (2012). Teaching and maintaining ethical behavior in a professional organization. Behavior Analysis in Practice, 5, 82–88.

Brodhead, M. T., Durán, L., & Bloom, S. E. (2014). Cultural and linguis- tic diversity in recent verbal behavior research on individuals with disabilities: a review and implications for research and practice. The Analysis of Verbal Behavior, 30, 75–86. doi:10.1007/s40616-014- 0009-8.

Carey, D., & Marques, P. (2007). From expert to collaborator. The Clinical Supervisor, 26, 141–157. doi:10.1300/J001v26n-01_10.

Cross, T. L., Bazron, B. J., Dennis, K.W., & Isaacs,M. R. (1989). Toward a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally dis- turbed. Retrieved from http://files.eric.ed.gov/fulltext/ED330171. pdf.

Diaz-Lazaro, C. M., & Cohen, B. B. (2001). Cross-cultural contact in counseling training. Journal of Multicultural Counseling and Development, 29, 41–56. doi:10.1002/j.2161-1912.2001.tb00502.x.

Fong, E. H., & Tanaka, S. (2013). Multicultural alliance of behavior analysis standards for cultural competence in behavior analysis. International Journal of Behavioral Consultation and Therapy, 8, 17–19.

Garcia, J. G., Cartwright, B., Winston, S. M., & Borzuchowska, B. (2003). A transcultural integrative model for ethical decisionmaking in counseling. Journal of Counseling & Development, 81(3), 268– 277. doi:10.1002/j.1556-6678.2003.tb00253.x.

Geiger, K. B., Carr, J. E., & LeBlanc, L. A. (2010). Function-based treatments for escape-maintained problem behavior: a treatment- selection model for practicing behavior analysts. Behavior Analysis in Practice, 3, 22–32.

Glenn, S. S. (1993). Windows on the 21st century. The Behavior Analyst, 16, 133–151.

Goldiamond, I. (2002). Toward a constructional approach to social prob- lems: ethical and constitutional issues raised by applied behavior analysis. Behavior and Social Issues, 11(2), 108–197.

Hayes, S. C., & Plumb, J. C. (2007). Mindfulness from the bottom up: providing an inductive framework for understanding mindfulness

processes and their application to human suffering. Psychological Inquiry, 18(4), 242–248. doi:10.1080/10478400701598314.

Hayes, S. C., & Toarmino, D. (1995). If behavioral principles are gener- ally applicable, why is it necessary to understand cultural diversity? The Behavior Therapist, 18, 21–23.

Hymes, D. (1962) The ethnography of speaking. In T. Glawinand W.C. Sturtevant (eds.). Anthropology and human behavior, 13–53. Washington, DC: Anthropological Society of Washington. Reprinted in J. A. Fishman, 1968. Readings in the Sociology of Language, 99–138. The Hague: Mouton.

Jibaja, M. L., Sebastian, R., Kingery, P., & Holcomb, J. D. (2000). The multicultural sensitivity of physician assistant students. Journal of Allied Health, 29, 79–85.

Jibaja-Rusth, M. L., Kingery, P. M., Holcomb, J. D., Bruckner, W. P., & Pruitt, B. E. (1994). Development of a multicultural sensitivity scale. Journal of Health Education, 25(6), 350–357. doi:10.1080/ 10556699.1994.10603060.

Jones, E. W., & Hoerger, M. L. (2009). Brief report: establishing ABA programs in a welsh context: cross-cultural considerations. European Journal of Behavior Analysis, 10, 249–253.

Kauffman, J. M., Conroy, M., Gardner, R., & Oswald, D. (2008). Cultural sensitivity in the application of behavioral principles in education. Education and Treatment in Children, 31, 239–262.

Lillis, J., & Hayes, S. C. (2007). Applying acceptance, mindfulness, and values to the reduction of prejudice: a pilot study. Behavior Modification, 31(4), 389–411. doi:10.1177/0145445506298413.

Montgomery, W. (2001). Creating culturally responsive, inclusive class- rooms. Teaching Exceptional Children, 33(4), 4–9.

Padilla Dalamau, Y. C., Wacker, D. P., Harding, J. W., Berg, W. K., & Schiettz, K. M. (2011). A preliminary evaluation of functional com- munication training effectiveness and language preference when Spanish and English are manipulated. Journal of Behavioral Education, 20, 233–251. doi:10.1007/s10864-011-9131-z.

Randall-David, E. (1989). Strategies for working with culturally diverse communities and clients. Washington, DC: Association for the Care of Children’s Health.

Rispoli, M., O’Reilly, M., Lang, R., Sigafoos, J., Mulloy, A., Auguilar, J., & Singer, G. (2011). Effects of language implementation on func- tional analysis outcomes. Journal of Behavioral Education, 20, 224–232. doi:10.1007/s10864-011-9128-7.

Rolider, A., & Axelrod, S. (2005). The effects of Bbehavior-speak^ on public attitudes toward behavioral interventions: A crosscultural ar- gument for using conversational language to describe behavioral interventions to the general public. In W. L. Heward, T. E. Heron, N. A. Neef, S. M. Peterson, D. M. Sainato, G. Cartledge, et al. (Eds.), Focus on behavior analysis in education: Achievements, challenges, and opportunities (pp. 283–294). Upper Saddle River: Pearson Press.

Salend, S. J., & Taylor, L. S. (2002). Cultural perspectives: missing pieces in the functional assessment process. Intervention in School and Clinic, 38(2), 104–112. doi:10.1177/10534512020380020601.

Skinner, B. F. (1953). Science and human behavior. New York: Collier- Macmillan.

Skinner, B. F. (1974). About behaviorism. New York: Knopf. Skinner, B. F. (1981). Selection by consequences. Science, 213, 501–504. Spring, B. (2007). Evidence-based practice in clinical psychology: what it

is, why it matters; what you need to know. Journal of Clinical Psychology, 63(7), 611–631. doi:10.1002/jclp.20373.

Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440–448. doi:10.1037/ 0003-066X.53.4.440.

Sue, D. W. (2003). Cultural competence in the treatment of ethnic minor- ity populations. In D. W. Sue (Ed.), Psychological treatment of ethnic minority populations (pp. 4–7). Washington, DC: APA Press.

Sugai, G., O'Keeffe, B. V., & Fallon, L. M. (2012). A contextual consid- eration of culture and schoolwide positive behavior support. Journal

94 Behav Analysis Practice (2016) 9:84–94

of Positive Behavior Interventions, 14(4). 197–208. doi:10.1177/ 1098300711426334.

Tanaka-Matsumi, J., Seiden, D. Y., & Lam, K. N. (1996). The Culturally Informed Functional Assessment (CIFA) interview: a strategy for cross-cultural behavioral practice. Cognitive and Behavioral Practice, 3(2), 215–233. doi:10.1016/S1077-7229(96)80015-0.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cul- tural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. doi:10.1353/hpu.2010.0233.

Tourinho, E. Z. (2006). Private stimuli, covert responses, and private events: conceptual remarks. The Behavior Analyst, 29(1), 13–31.

U.S. Department of Health and Human Services. (2001). Mental health: culture, race and ethnicity. A supplement to mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health

and Human Services, U.S. Public Health Services, Office of the Surgeon General.

Vandenberghe, L. (2008). Culture-sensitive functional analytic psycho- therapy. The Behavior Analyst, 31(1), 67.

Washio, Y., & Houmanfar, R. (2007). Role of contextual control in sec- ond language performance. The Analysis of Verbal Behavior, 23, 41–56.

Westefeld, J. S., & Rasmussen, W. (2013). Supervision: the importance and interaction of competency benchmarks and multiculturalism. The Counseling Psychologist, 41, 110–123. doi:10.1177/ 0011000012453945.

Wolfe, K., & Durán, L. K. (2013). Culturally and linguistically diverse parents’ perceptions of the IEP process: a review of current research. Multiple Voices for Ethnically Diverse Exceptional Learners, 13, 4– 18.

Behavior Analysis in Practice https://doi.org/10.1007/s40617-019-00351-8

SPECIAL SECTION: DIVERSITY AND INCLUSION

Culture Always Matters: Some Thoughts on Rosenberg and Schwartz

Matthew T. Brodhead1

# Association for Behavior Analysis International 2019

Abstract The purpose of this paper is to draw attention to and highlight some particularly enlightening arguments described by Rosenberg and Schwartz (2019). First, I emphasize the importance of the role of culture in ethical analysis and describe how the Behavior Analyst Certification Board (BACB) Professional and Ethical Compliance Code for Behavior Analysts (2014; hereafter referred to as the BACB Code) unintentionally underplays the importance of culture. Second, I express support for the model of ethical analysis proposed by Rosenberg and Schwartz and explain how their model provides an excellent and much-needed framework for the observation (and subsequent study) of ethical decision-making in behavior-analytic practice. Finally, I go all in and join Rosenberg and Schwartz in their call for scholars to critically analyze and discuss the BACB Code and to challenge the status quo (or call into question those who do). Such a discussion is healthy for our science and understanding of ethics and behavior analysis.

Keywords applied behavior analysis . culture . ethics . decision-making models . dissent

Culture Always Matters

A behavioral analysis of culture is not new. Skinner discussed the role of culture (defined as contingencies arranged by other people) in multiple writings, including Science and Human Behavior (1953), Walden Two (1976), and his paper “Selection by Consequences” (1981). Sugai, O’Keefe, and Fallon (2012) provide a more contemporary definition of cul- ture, defining culture as “the extent to which a group of indi- viduals engage in overt and verbal behavior reflecting shared behavioral learning histories, serving to differentiate the group from other groups, and predicting how individuals within the group act in specific setting conditions” (p. 200). In addition to behavioral definitions of culture, other scholars, such as Sigrid Glenn (e.g., 1993), Mark Mattaini (e.g., 2010), and Maria Malott (e.g., 1992) have written extensively about the role of cultural variables and their effects on human behavior.

Culture goes well beyond one’s geographical identity. Sexual identity, socioeconomic status, and opinions about medicine, politics, and science are all but a few examples of broad and impactful cultural variables that affect the everyday

* Matthew T. Brodhead [email protected]

behavior of ordinary people. Consider the simple example of the cultural selection of verbal behavior. Coffee may be a learned reinforcer, but the mand forms that result in access to coffee (e.g., “Quiero café por favor” or “May I have some coffee?”) are culturally selected (Brodhead, Durán, & Bloom, 2014). I challenge the reader to identify nonexamples of cul- tural variables in order to emphasize the importance and enor- mity of how our social constructs affect what we say and do.

The field of behavior analysis is a cultural system (see Glenn, 1993) that is informed by the values of Western med- icine (Brodhead, Cox, & Quigley, 2018a). As Rosenberg and Schwartz (2019) astutely note, the very existence of a rule- based system is a Western-centric belief. I note that this is not a criticism of our science and scientists, per se. Instead, I intend to further highlight that our core values, such as our philo- sophical values of determinism (Skinner, 1953) and what de- fines applied behavior analysis (Baer, Wolf, & Risley, 1968), are built upon just one of many perspectives upon which we are able to draw to assemble our own worldview. Put another way, the Western model is one of many cultures that may exert control over human behavior. From a point of binary compar- ison, a Western model of medicine may view environmental changes as primary variables in behavioral health and treat- ment, whereas the Eastern model of medicine may instead emphasize the consideration of the body and mind in behavior-change procedures (World Health Organization,

Michigan State University, East Lansing, MI 48824, USA 2000). 1

Behav Analysis Practice

Despite the scholarly definitions of culture and a small but emerging base of research on this topic in behavior analysis, the role of culture has been largely neglected in behavior- analytic scholarship on ethical analysis. When discussions of the role of culture in ethical analysis do exist, they have main- ly centered around considerations of variables to take into account when interacting and providing services to diverse clients. One specific example is the cultural practice of gift giving or exchanging. Bailey and Burch (2016) note that one of the most talked about elements of the Behavior Analyst Certification Board’s (BACB’s) Professional and Ethical Compliance Code for Behavior Analysts (2014; hereafter referred to as the BACB Code) has centered around BACB Code 1.06d, which states that “behavior analysts do not accept any gifts from or give any gifts to clients because this consti- tutes a multiple relationship.” In addition to noting the popu- larity of BACB Code 1.06d, Bailey and Burch make the ar- gument that cultural analysis is irrelevant when considering this code in ethical analysis. Specifically, they liken behavior analysts to tradespeople (e.g., a plumber or electrician) and say that “it seems nonsensical to expect these tradespeople to bring gifts or accept them” (p. 73). They argue that the cultural experience of gift exchange is not relevant to behavior analysis and requires no further consideration or analysis.

The recommendation that cultural analysis is “nonsensical” is incongruent with what is known to be best practice in cul- tural competence in human-service delivery (Fong, Catagnus, Brodhead, Quigley, & Field, 2016; Witts, Brodhead, Adlington, & Barron, 2018). Cultural competence, in fact, is a two-way street, a respectful convergence of ideas (e.g., cul- tural variables) that results in the development and implemen- tation of optimal treatment (Bolling, 2002). Cultural compe- tence does not mean that our clients should only cross the street in our direction.

As noted by Rosenberg and Schwartz, cultural variables greatly add to the complexity of ethical analysis. Unfortunately, the BACB Code has not focused on the impor- tance of culture in ethical analysis. In addition to Bailey and Burch’s (2016) dismissal of certain cultural practices in ethical analysis, only in BACB Code 1.05 (Professional and Scientific Relationships) is the term culture mentioned, and only briefly by noting that the behavior analyst must resolve any differences in culture that affect services. As Rosenberg and Schwartz point out, culture is much more important and complex than what I am sure was meant when the current version of the BACB Code was written or how it is portrayed in popular texts on ethics and behavior analysis.

I hypothesize that the direct and specific language of BACB Code 1.06d has created a black-and-white approach to ethical decision-making that may affect people who are new to our field. Furthermore, I fear this approach has overgeneralized to other elements of the BACB Code. This is the same decision-making process that Rosenberg and

Schwartz argue against, and they make clear that rigid think- ing may result in a superficial ethical analysis, at best.1 But because of BACB Code 1.06d, there may be unintended con- sequences of overcorrection to prevent multiple relationships (Brodhead et al., 2018a) at the expense of potentially a greater problem of creating a brand of practitioners who risk being insensitive to the nuances of culture.

Another unintended consequence of the BACB Code is that the behavior analyst is forever stuck in an ethical dilemma of deciding whether to respect cultural differences (BACB Code 1.05) by accepting a gift while simultaneously violating another element of the BACB Code (1.06d). I offer this as one example of at least a few places where the BACB Code may face criticism and contradiction within itself. In another exam- ple, Graber and O’Brien (2018) describe how, when behavior analysts are not fully reimbursed for behavioral services, the ethical dilemma that arises from the options of discontinuing services, prioritizing of services to clients who can pay out of pocket, or providing less care in terms of hours to clients places the behavior analyst in a no-win ethical situation. In a final example, Graber and Graber (2018) note that “from the perspective of ethical theory, the Code’s restriction on punish- ment is likely inaccurate” (p. 4). To briefly summarize, be- cause it is a nonsubjective term (i.e., it is defined by objective observation of behavior over the passage of time), punishment is generally not subject to moral evaluation in ethical theory. In the aforementioned cases, I do not believe the BACB intended for the BACB Code to be conflicting in these ways. Nor can the BACB possibly account for every possible instance in which their ethical codes may or may not conflict with one another or cause confusion (Brodhead et al., 2018a). These discrepancies are common in the realm of professional ethics (see Graber & Graber, 2018, for further discussion). As scholars, it is our job to point them out and to encourage careful analysis and revision to our ethics codes. As readers, I see it as your duty to digest these arguments and to proceed with caution in similar situa- tions, knowing the complexity of those situations.

It is important to emphasize that BACB Code 1.06d, as well as the entire BACB Code itself, is designed to protect consumers of behavior-analytic services and the behavior an- alysts providing those services. That is, 1.06d may very well serve as an antecedent intervention that decreases the likeli- hood of a behavior analyst entering a multiple relationship, which then results in maintained compliance with the BACB Code and decreases the probability of disciplinary action and impaired clinical judgement stemming from a multiple rela- tionship. Furthermore, because only individuals credentialed by the BACB can be held liable for violations of the BACB

1 My informal observations also suggest that BACB Code 1.06d has resulted in a surge of “Should you take a glass of water from a client?” presentations at the Association for Behavior Analysis International’s and other conferences, likely detracting from more important and meaningful discussions related to ethics and behavior analysis.

Behav Analysis Practice

Code, the code serves as a layer of protection for the behavior analyst in the event an organizational policy is incongruent with the BACB Code (Brodhead, Quigley, & Cox, 2018b). In an ethical analysis, the stated cultural values of the BACB Code, to protect consumers and the behavior analyst, must be kept in mind. Any behavior analyst bound to the BACB Code must do his or her due diligence to minimize noncompliance with it; at the same time, behavior analysts must do their due diligence to maintain respectfulness and appreciation for cul- tural values, as well as maintain actions that protect their credential.

Given the current trend in behavior analysis to further un- derstand the role of culture in service delivery and to advocate for cultural competence (e.g., Beaulieu, Addington, & Almeida, 2018; Brodhead et al., 2014; Fong & Tanaka, 2013; Fong et al., 2016; Li, Wallace, Ehrhardt, & Poling, 2017), including an ethical analysis (Rosenberg & Schwartz, 2019; Witts et al., 2018), I am encouraged that the next revi- sion of the BACB Code will resolve some of the confusion surrounding culture. In all likelihood, different problems may emerge that spark additional scholarly conversations. For those cases, Rosenberg and Schwartz serve as a model as to how we may critically analyze the BACB Code to help guide us through ethical analyses when an ethical dilemma is present.

To conclude this section, I emphasize that ignoring the culture of our clients, and ourselves, in ethical analysis is incongruent with our core value of being analytic (see Baer et al., 1968). Disregarding the importance of culture also does not align with what is known to be best practices in cultural competence (see Fong & Tanaka, 2013; Fong et al., 2016). Rosenberg and Schwartz challenge the status quo put forth by the BACB Code and popular texts on ethics and behavior analysis by drawing attention to this fact. I hope that readers take away from Rosenberg and Schwartz the importance of the role of culture in service delivery and ethical analysis. I also hope readers understand that although the BACB Code may underemphasize the importance of culture, culture is far from unimportant in ethical analysis.

We Need Operationalized Processes of Ethical Decision-Making

Recently, behavior analysts have begun to describe and eval- uate systematic processes for making decisions during behavior-analytic practice. Examples include models for en- gaging in effective interdisciplinary collaboration, selecting types of function-based treatments, and accurately analyzing data (Brodhead, 2015; Geiger, Carr, & LeBlanc, 2010; Kipfmiller et al., 2019; Newhouse-Oisten, Peck, Conway, & Frieder, 2017). A primary benefit of the aforementioned models is that they provide a framework for operationally

defining, and subsequently measuring, observable behaviors of practicing behavior analysts.

The model proposed by Rosenberg and Schwartz extends this previous work and introduced a tool that finally allows us to define, observe, and measure ethical decision-making be- havior. I, for one, am personally excited about this contribu- tion. Until now, we have failed to hold ethical analysis to the same standards as other components of applied practice, stan- dards of objectively defining, observing, measuring, and ana- lyzing behavior.

I draw upon the area of autism treatment to further high- light the importance of the contribution made by Rosenberg and Schwartz. Scholars have very carefully operationally de- fined the components that are necessary for well-implemented and effective discrete-trial instruction. Likewise, the assess- ment and treatment of challenging behavior have received consistent attention over the course of decades, with much detail paid to variations and situation-specific modifications that result in optimal treatment outcomes. Discrete-trial teach- ing, functional assessment, and treatment of challenging be- havior are certainly important. But ethics are also important— so important that I argue they are the umbrella that covers all that we do.

So where is the same treatment and attention paid to oper- ationally defining ethical behavior, so it can be observed or taught, just as we observe or teach discrete trials and function- al assessments? Rosenberg and Schwartz show us that opera- tionally defining the behavioral process of ethical analysis can be done, and done well. Their model sends a message to stu- dents, practitioners, and scholars that the wait is over for the objective study of ethics in behavior analysis. Gone are the days where we must rely on telling our students and supervisees “what not to do” in order to follow the BACB Code. Also gone are the days where we must rely on case studies that do not reflect the specific challenges we may face to teach ethical decision-making. Though these case studies may be important in establishing a baseline level of under- standing in ethical analysis, they do not account for the situation-specific instances a behavior analyst may face during clinical practice (see Chapter 3 in Brodhead et al., 2018a). Instead, we now have a tool, rooted in behavior-analytic tra- dition, for teaching our students and supervisees how to be analytical during their ethical decision-making process in rel- evant practice settings (just as we would expect them to be analytical during their discrete-trial instruction and functional assessment process).

Do not forget that ethical behavior, like most behavior, is a discriminated operant (Newman, Reinecke, & Kurtz, 1996). We would never assume our employees could learn discrete- trial teaching through osmosis; ethical behavior is no different. Rosenberg and Schwartz get a pass on this, but the rest of us should be accountable for holding ethics to the same behavior- analytic standards as our other practices.

Behav Analysis Practice

I call upon scholars to study the model proposed by Rosenberg and Schwartz. To date, there are no empirical stud- ies on ethics and behavior analysis. I find this rather heart- breaking, given the importance of ethics as a subject matter, and the emphasis the BACB places on coursework and con- tinuing education in ethics. But now, we have run out of ex- cuses (myself included) for not studying such an important component of our practice. We now have a framework for at least the partial empirical study of ethics and behavior analysis.

Challenging the Status Quo Is Healthy

Very few scholars have come forth to critically analyze the BACB Code. Rosenberg and Schwartz serve as one example—one that takes issue with the mandated compliance required by the BACB and the rule-based BACB Code. Witts et al. (2018), Graber and O’Brien (2018), and Graber and Graber (2018) serve as three other critical analyses of the BACB Code that I am aware of. Surely, there are other scholars who have comments on the BACB Code (either for or against), and I encourage them to step forward and join the discussion. As Pat Friman (2010) noted in a not-at-all-related article, “Come on in, the water is fine.”

Behavior analysts contact and engage with the BACB Code on a continuous basis. Whereas we are continuously analyzing and questioning our treatment practices as a means to stay close and true to our behavior-analytic values, surely behavior analysts are engaging in similar conversations about the BACB Code, a document that bears enormous weight, responsibility, and directive for how we behave. Aside from any licensure laws behavior analysts may be bound to and the BACB Task List (BACB, 2012) that defines our scope of prac- tice, I know of no other documents that bear as much impor- tance as the BACB Code. Let us help shape it.

To be complacent and indifferent to the BACB Code, I argue, is to go against the core values of what it means to be a behavior analyst. Without a critical analysis of the BACB Code, the A in Analyst is missing, and if it exists, it is a tiny, lowercase a that is too small for print. Dissent, in general, is healthy for a science and allows it to grow and mature much better than if its values were not questioned and we are led into compliance and groupthink.

Summary

My preference for dissent and challenging widely held con- ventions is likely a product of my teenage years, where I did nothing but skateboard (poorly), listen to punk rock (loudly), and read George Orwell (enthusiastically). I understand if others are not so welcoming to the idea of dissent and

challenging important documents (e.g., the BACB Code). I recognize that preference for compliance is likely a result of one’s own individual learning history—a cultural value that one may hold dear.

My cultural values of dissent and calling into question things of importance may be incompatible with those of com- pliance. I welcome further discussion about how our values may converge in order to achieve the goal in which I believe we are all here to realize: the development of a science of behavior that produces socially significant (and ethical) be- havior change. I hope you join us in this discussion. Until then, I’ll be hanging out with Rosenberg and Schwartz, at least until others join in and change my mind.

Come on in, the water is fine.

Author Note Matthew T. Brodhead, Department of Counseling, Educational Psychology, and Special Education, Michigan State University.

I thank my graduate students for their careful reading of an earlier version of this manuscript.

This paper is based off a presentation given at the 2018 Association for Behavior Analysis Conference in San Diego International, California.

Compliance with Ethical Standards

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

Conflict of interest The author declares that he has no conflicts of interest.

References

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimen- sions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, 91–97. https://doi.org/10.1901/jaba.1968.1-91.

Bailey, J., & Burch, M. (2016). Ethics for behavior analysts (3rd ed.). New York, NY: Routledge

Beaulieu, L., Addington, J., & Almeida, D. (2018). Behavior analysts’ training and practices regarding cultural diversity: The case for cul- turally competent care. Behavior Analysis in Practice. Advance on- line publication. https://doi.org/10.1007/s40617-018-00313-6.

Behavior Analyst Certification Board. (2012). Fourth Edition Task List. Retrieved from https://www.bacb.com/wp-content/uploads/2017/ 09/160101-BCBA-BCaBA-task-list-fourth-edition-english.pdf.

Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for behavior analysts. Retrieved from https://bacb. com/ethics-code/.

Bolling, M. T. (2002). Research and representation: A conundrum for behavior analysts. Behavior and Social Issues, 12, 19–28. https:// doi.org/10.5210/bsi.v12i1.76.

Brodhead, M. T. (2015). Maintaining professional relationships in an interdisciplinary setting: Strategies for navigating nonbehavioral treatment recommendations for individuals with autism. Behavior

Behav Analysis Practice

Analysis in Practice, 8, 70–78. https://doi.org/10.1007/s40617-015- 0042-7.

Brodhead, M. T., Cox, D. J., & Quigley, S. P. (2018a). Practical ethics for effective treatment of autism spectrum disorder. New York, NY: Academic Press.

Brodhead, M. T., Durán, L., & Bloom, S. E. (2014). Cultural and linguis- tic diversity in recent verbal behavior research on individuals with disabilities: A review and implications for research and practice. The Analysis of Verbal Behavior, 30, 75–86. https://doi.org/10.1007/ s40616-014-0009-8.

Brodhead, M. T., Quigley, S. P., & Cox, D. J. (2018b). How to identify ethical organizations prior to employment. Behavior Analysis in Practice, 11, 165–173. https://doi.org/10.1007/s40617-018-0235-y.

Friman, P. C. (2010). Come on in, the water is fine: Achieving main- stream relevance through integration with primary medical care. The Behavior Analyst, 33, 19–36.

Fong, E. H., Catagnus, R. M., Brodhead, M. T., Quigley, S., & Field, S. (2016). Developing cultural awareness skills of behavior analysts. Behavior Analysis in Practice, 9, 84–94. https://doi.org/10.1007/ s40617-016-0111-6.

Fong, E. H., & Tanaka, S. (2013). Multicultural alliance of behavior analysis standards for cultural competence in behavior analysis. International Journal of Behavioral Consultation and Therapy, 8, 17–19.

Geiger, K. B., Carr, J. E., & LeBlanc, L. A. (2010). Function-based treatments for escape-maintained problem behavior: A treatment selection model for practicing behavior analysts. Behavior Analysis in Practice, 3 , 22– 32. https://doi.org/10.1007/ BF03391755.

Glenn, S. S. (1993). Windows on the 21st century. The Behavior Analyst, 16, 133–151.

Graber, A., & Graber, J. E. (2018). The unique challenge of articulating the behavior analysts’ ethical obligations and the case of punish- ment. Behavior Analysis in Practice. Advance online publication. https://doi.org/10.1007/s40617-018-00310-9.

Graber, A., & O’Brien, M. (2018). The promise of accountable care organizations: “The Code,” reimbursement, and an ethical no-win situation for behavior analysts. Behavior Analysis in Practice. Advance online publication. https://doi.org/10.1007/s40617-018- 0209-0.

Kipfmiller, K. J., Brodhead, M. T., Wolfe, K., Lalonde, K., Sipila, E. S., Bak, M. Y. S., & Fisher, M. H. (2019). Training front-line employees to conduct visual analysis using a clinical decision-making model.

Journal of Behavioral Education. Advance online publication. https://doi.org/10.1007/s10864-018-09318-1.

Li, A., Wallace, L., Ehrhardt, K. E., & Poling, A. (2017). Reporting participant characteristics in intervention articles published in five behavior-analytic journals, 2013–2015. Behavior Analysis: Research and Practice, 17, 84–91. https://doi.org/10.1037/ bar0000071.

Malott, M. E. (1992). Designing a humanitarian culture: An analysis of the Cuban experiment. Behavior and Social Issues, 2, 99–118.

Mattaini, M. (2010). Editorial: Cultural analysis and social change in Medellin. Behavior and Social Issues, 19, 1–5.

Newhouse-Oisten, M. K., Peck, K. M., Conway, A. A., & Frieder, J. E. (2017). Ethical considerations for interdisciplinary collaboration with prescribing professionals. Behavior Analysis in Practice, 10, 145–153. https://doi.org/10.1007/s40617-017-0184-x.

Newman, B., Reinecke, D. R., & Kurtz, A. L. (1996). Why be moral: Humanist and behavioral perspectives. The Behavior Analyst, 19, 273–280.

Rosenberg, N., & Schwartz, I. (2019). Guidance or compliance: What makes an ethical behavior analyst? Behavior Analysis in Practice. https://doi.org/10.1007/s40617-018-00287-5.

Skinner, B. F. (1953). Science and human behavior. New York, NY: The Free Press.

Skinner, B. F. (1976). Walden two. Indianapolis, IN: Hackett. Skinner, B. F. (1981). Selection by consequences. Science, 213, 501–504. Sugai, G., O’Keeffe, B. V., & Fallon, L. M. (2012). A contextual consid-

eration of culture and school-wide positive behavior support. Journal of Positive Behavior Interventions, 14, 197–208. https:// doi.org/10.1177/1098300712442242.

Witts, B. N., Brodhead, M. T., Adlington, L. A., & Barron, D. (2018). Behavior analysts accept gifts during practice: So now what? Behavior Analysis: Research and Practice. Advance online publi- cation. https://doi.org/10.1037/bar0000117.

World Health Organization. (2000). General guidelines for methodolo- gies on research and evaluation of traditional medicine. Retrieved on January 17, 2019, from whqlibdoc.who.int/hq/2000/WHO_ EDM_TRM_2000.1.pdf.

Publisher’s Note Springer Nature remains neutral with regard to jurisdic- tional claims in published maps and institutional affiliations.