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Using acceptance and commitment training to enhance the effectiveness of behavioral skills training

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Using acceptance and commitment training to enhance the effectiveness of behavioral skills training

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Content Running Head: EFFECT OF ACT TRAINING ON BST 1

Using Acceptance and Commitment Training
To Enhance the Effectiveness of Behavioral Skills Training
Alexandra Little and Jonathan Tarbox
Master of Science in Applied Behavior Analysis
University of Southern California
May 10
th
, 2019

EFFECT OF ACT TRAINING ON BST 2
Table of Contents
Abstract .................................................................................................................................. 3
1.0 Introduction ..................................................................................................................... 4
1.1 Acceptance and Commitment Training .................................................................................... 6
1.1.1 Values ........................................................................................................................................................ 7
1.1.2 Present moment attention ........................................................................................................................ 8
1.1.3 Acceptance ................................................................................................................................................. 9
1.1.4 Defusion ................................................................................................................................................... 10
1.1.5 Self-as-context ......................................................................................................................................... 11
1.1.6 Committed action ................................................................................................................................... 12
2.0 Method ............................................................................................................................ 15
2.1 Participants and Setting .......................................................................................................... 15
2.2 Response Measurement ........................................................................................................... 16
2.2.1 Dependent Variables. ............................................................................................................................. 16
2.2.2 Data Collection. ....................................................................................................................................... 16
2.2.3 Interobserver agreement ........................................................................................................................ 16
2.3 Design ...................................................................................................................................... 16
2.4 Procedures ............................................................................................................................... 17
2.4.1 Baseline .................................................................................................................................................... 17
2.4.2 Behavioral Skills Training ..................................................................................................................... 17
2.4.3 Acceptance and Commitment Training ................................................................................................ 18
2.4.4 Social Validity Measure ......................................................................................................................... 21
3.0 Results ............................................................................................................................. 21
4.0 Discussion ....................................................................................................................... 22
References ............................................................................................................................ 27
Appendix ............................................................................................................................... 30

EFFECT OF ACT TRAINING ON BST 3
Abstract
The purpose of this study is to investigate the use of acceptance and commitment training (ACT)
to increase the percent per opportunity of behavioral skills training (BST) use in a train the
trainer model within an ABA clinic. Acceptance and commitment training exercises are modeled
off of the six processes for change consisting of values, present moment attention, acceptance,
defusion, self as context, and committed action. This study included three participants, all of
whom were RBT trained and had been working in the field for at least 6 months. This study
utilized an ABC design embedded within a multiple baseline across participants. Each
participant engaged in an initial BST instruction in which behavior skills training was used to
teach senior staff how to train using BST. Data were then taken on the percent per opportunity of
BST used with new staff in session. ACT training was conducted for all of the participants after
BST alone did not produce sufficient results. The addition of ACT was found to be effective in
increasing the percent per opportunity of BST used by senior therapists to train new staff, the
results generalized to trainees who were not present during ACT training, and maintained after
ACT training was terminated.

EFFECT OF ACT TRAINING ON BST 4
Using Acceptance and Commitment Training
To Enhance the Effectiveness of Behavioral Skills Training
1.0 Introduction
A substantial amount of research has established the effectiveness of applied behavior
analytic (ABA) interventions for individuals with autism (Virués-Ortega, 2010). This research
has led to laws requiring insurance companies to fund ABA treatment, resulting in a large and
rapid expansion in the demand for ABA services (Glass, 2015). As the field grows, so does the
need for quality therapists; the training of behavioral therapists therefore is more important today
than perhaps ever before. While substantial research has shown which training procedures are
effective, many ABA clinics do not implement empirically validated models consistently.
Behavior skills training (BST) is one of the most scientifically supported procedures for
training new staff. Behavior skills training (BST) involves a three-step model (Nigro-Bruzzi &
Sturmey, 2010). The first step is verbal instruction in which the trainer provides a description of
a skill, discusses the importance or rationale, and when to and not to use it. The second step
consists of the trainer modeling how to perform the skill. The third step consists of role-play
rehearsal with feedback, which allows the individual to practice the skills and receive immediate
feedback from the trainer. During this step, the trainer provides praise for correct responses and
corrective feedback for incorrect responses. Role-play with feedback is generally continued until
the trainee demonstrates accurate performance according to a predetermined criterion, for
example, at least 90% correct implementation.
A substantial amount of research shows the effectiveness of BST in training a variety of
ABA skills. Sarokoff and Sturmey (2004) evaluated the use of BST to train three special
education teachers working with a child with ASD to implement discrete trial training (DTT).
The results show that BST produced rapid improvements in the teachers’ implementation of
EFFECT OF ACT TRAINING ON BST 5
DTT (Sarokoff & Sturmey, 2004). Additionally, previous research used BST to teach staff to
implement most-to-least prompting, as well as how to use manual signs for communication with
clients (Parsons, Rollyson, & Reid, 2012). In this study, the researchers provided a written
description of the target skill during the verbal explanation phase, as is often done in BST.
Following the intervention all participants showed an increase in proficient use of most-to-least
prompting as well as signing skills.
The research described above provides evidence for the effectiveness of BST, but it may
be difficult to use a standard BST model to train a sufficient number of staff in a rapid enough
manner to meet the demand. An alternative to having one expert trainer use BST to directly train
all staff in an organization, is to use a train-the-trainer model. The train-the-trainer model
involves training mid-level staff to use BST to train incoming and lower level employees, thus
expanding the efficiency of training in the organization. Train-the-trainer programs are used in
multiple fields such as public health, safety, education, and health care (Yarber et al., 2015).
There are multiple advantages to the train-the-trainer programs, however the largest and most
applicable to the field of ABA is the ability to train a larger number of people per unit of time
(Yarber et al., 2015). BST has been used with senior staff to teach them how to implement BST
when training new staff within the work setting (Parsons, Rollyson, & Reid, 2013). However,
previous research has focused on training senior staff members to train another staff member in a
small number of work-related skills. In many ABA clinics, it is necessary for new incoming staff
to be trained in a variety of work-related skills. This task however can be daunting to senior staff
preparing to train as they are expected to not only provide effective therapy, but to also provide
effective training. Additional research may therefore be needed on ways to enhance the
effectiveness of a BST train-the-trainer model, when this model alone does not produce
sufficient behavior change.
EFFECT OF ACT TRAINING ON BST 6
Implementing BST inside of a train-the-trainer model can be difficult for staff. The job of
ABA therapists and trainers working with families with autism is inherently stressful and
research suggests burnout can be a significant problem in this discipline (Hurt, Grist, Malesky, &
McCord, 2013). It is not common for ABA training approaches to address private events, but
staff often report that private events play a role in the difficulty of implementing effective staff
training. For example, therapists may report that they experience private events such as stress,
feelings of fatigue or frustration, and thoughts that they are unprepared or inadequate to the task
of training. If treated as hypothetical internal causes of behavior, these covert variables are of
little use in a science of behavior. However, when treated as private environmental events, for
example as aversive stimuli and maladaptive rules or discriminative stimuli, it should be possible
to address them in a behavioral approach to staff training and performance. If private events are
simply behavior and environment, then they should be amenable to analysis and intervention
according to the same behavior analytic principles that govern everything else we do in behavior
analysis, in addressing functional relations between overt behavior and environment (Skinner,
1974).
1.1 Acceptance and Commitment Training
Acceptance and commitment training (ACT) is a contemporary behavior analytic
approach to addressing private events. ACT was originally developed as a behavior analytic
approach to psychotherapy and is still called acceptance and commitment therapy when
implemented in that setting. More recently the term acceptance and commitment training has
been used to refer to ACT when it is applied in non-psychotherapeutic settings. ACT is a
mindfulness-based approach to behavior change that focuses on increasing behavioral flexibility.
A main conceptual functional analysis at the foundation of ACT is that sub-optimal performance
often involves behavior that is maintained by escape from or avoidance of aversive private
EFFECT OF ACT TRAINING ON BST 7
events, referred to “experiential avoidance” in the ACT literature (Zarling, Lawrence, &
Marchman, 2015). In other words, experiential avoidance is an attempt to avoid private events,
such as undesirable thoughts, feelings, and bodily sensations (Hayes, 2004). As an alternative to
escape-maintained behavior, ACT aims to train individuals to function effectively in the
presence of challenging private events by behaving more flexibly and toward overt, large but
long-delayed positive reinforcers, referred to as “values” in the ACT literature.
Interventions informed by ACT target six component repertoires of behavior (referred to
as “processes” in the ACT literature), all of which interact with one another, to achieve socially
meaningful overt behavior change (Hayes, et. al. 2012). Figure 1 depicts these six behavioral
repertoires, including values, present moment attention, acceptance, defusion, self-as-context,
and committed action (Hayes, Pistorello, & Levin, 2012). These terms are not technical terms in
behavior analysis, but all were originally developed and understood from a behavioral
perspective. Each refers to both: 1) a complex functional relation between behaviors and
environmental events, and 2) procedures used to strengthen these behavioral repertoires (much in
the same way as the term “reinforcement” refers both to a relation between behavior and
consequences that strengthen it, as well as to procedures used to reinforce behavior in practice).
1.1.1 Values. From a functional analytic standpoint, the term values refer to large classes
of verbally constructed, highly potent, long-term positive reinforcers. For example, seeing a child
succeed in school, hearing a parent tell you that they are able to take their child out to eat at a
restaurant for the first time, and seeing that child make friends and succeed socially, may be in a
hierarchical relational class with values statements such as “making a difference as a behavior
analyst.” As procedures, values-based interventions involve statements or rules that function as
verbal motivating operations, that increase or decrease the effectiveness of stimuli as reinforcers
or punishers, in turn supporting committed action in the form of overt behavior. For example,
EFFECT OF ACT TRAINING ON BST 8
within a staff training model, the director of training may ask the senior therapists “What drives
you to come into work each day and to provide therapy for your client?” The senior therapists
may say something along the lines of “I am driven knowing that what I am doing will help teach
my client to communicate her needs for the rest of her life.” The director of training can then link
the importance of providing quality training to new staff with that senior therapist’s core value of
helping a child to communicate. For example, “I can draw a direct line between each hour that I
put into training staff and the outcomes their clients are going to have in the future. If I do a great
job at training, it could literally mean the difference between a kid learning the words to be able
to say, ‘I love you’ to his mom for the first time.” This in turn may increase the senior therapist’s
commitment to providing quality training, perhaps by making training, itself, less aversive or
more positively reinforcing.
1.1.2 Present moment attention. Present moment attention as a behavioral repertoire is
an individual’s behavior of attending to stimuli in the present moment as opposed to attending to
one’s own verbal behavior surrounding the past, future, or imagined events. For example, in the
context of providing staff training, a strong repertoire of present moment attention for the trainer
would consist of most of her attending behavior being oriented to the trainee, the client, and
other relevant variables of the training situation. A relatively weaker present moment repertoire
for the trainer could involve more of her attending behavior being directed to private stimuli,
such as the thought “If I tell this person they aren’t doing a good job, they might not like me, or
they might quit.”
In addition to paying attention to the present moment, present-moment-attention behavior
involves learning to attend to one’s own attending behavior. This can involve tacting your own
attending behavior, including when it is in the present, versus when it wanders, which can then
serve as a discriminative stimulus for redirecting your attention back to the present moment. Put
EFFECT OF ACT TRAINING ON BST 9
differently, present moment attention involves building the repertoire of self-managing your own
attending behavior. For senior staff tasked with training, a strong present moment repertoire
could involve noticing when they are actually paying attention to the staff member they are
training, versus when they are attending to their own problematic private events (e.g. “Am I good
enough at ABA to be teaching it?”). The behavior of tacting one’s attention to one’s own private
events may then serve as a discriminative stimulus for the staff member to return to the present
moment, much like the behavior of noticing oneself not paying attention while driving may help
one orient one’s attention back to driving. When one is more engaged in one’s own difficult
private events, this may encourage behaviors that avoid situations that evoke those private
events, for example, avoid giving a new staff member meaningful feedback.
A variety of procedures have been developed for training present moment attending
behavior, but most come from mindfulness meditation. For example, a person might be asked to
close their eyes and focus on their breath. When they notice their attention wander, bring it back
to their breath. Meditative exercises are often used to train this repertoire initially, but trainees
are encouraged to notice their own attending behavior across all aspects of their lives (e.g., while
working, while driving, while doing household chores, while conversing with friends, etc.) and
the goal is for one’s present moment repertoire to be strengthened generally, so less self-
management of that repertoire is needed over time.
1.1.3 Acceptance. As a behavioral repertoire, acceptance can be thought of as the
behavior of staying present (absence of avoidance or escape) when presented with aversive
stimulation and sometimes actively moving toward the aversive stimulus. For example, if a
trainer experienced the aversive thought (private event) “The trainee doesn’t think I am qualified
to train her,” rather than engaging in avoidance behavior, such as canceling their training session
or skipping teaching a skill, they instead purposefully observe their feelings of being inadequate.
EFFECT OF ACT TRAINING ON BST 10
Acceptance training often involves practicing observing, noticing, and “making room for” their
aversive private events. Rather than avoiding, acceptance behavior involves contacting aversives.
As a procedure, acceptance training involves prompting and reinforcing multiple
exemplars of experiencing something aversive and not moving away. For example, if a staff
trainer has the thought “She’s going to freak out if I give her corrective feedback,” rather than
avoiding giving feedback, the trainer might write the thought on a piece of paper and hold it in
her hands. Or when checking her email, instead of avoiding reading a message from an angry
staff member, the trainer might read the message and notice how her heart rate elevates, skin
feels warm, or how she feels angry or annoyed. The rationale for acceptance is that, if one’s
repertoire of escaping aversives is weakened, it can provide more opportunity to engage in a
variety of other behaviors that could lead to positive reinforcement (e.g., having a meaningful,
constructive training session with a trainee). In this way, a previously aversive private event that
may lead to avoidance or escape behavior may now be an occasion to access positive
reinforcement by engaging in a values-based behavior.
1.1.4 Defusion. As a behavioral repertoire, defusion is described as a weakening of rigid
rule control over behavior. Behavioral repertoires labeled as “defused” consist of broader, more
flexible responding to aversive private events, particularly those involving unhelpful rules
describing avoidance. It is often useful to contrast defusion (an adaptive repertoire of behavior)
with “fusion,” a maladaptive repertoire of behavior that defusion is meant to replace. Behavior
that is labeled as “fused” involves responding rigidly and in an overly “compliant” way with
one’s own unhelpful rules regarding aversive stimuli. For example, overly rigid responding to
the thought “I am an introvert” when providing staff training might encourage the trainer to
avoid giving feedback. A more defused repertoire might involve noticing the thought “I am an
introvert” and then trying a few different ways to respond to that thought in the context of
EFFECT OF ACT TRAINING ON BST 11
training (e.g., sometimes staying silent, sometimes giving feedback, sometimes asking the trainee
a question).
To strengthen these flexible “defusion repertoires,” defusion procedures teach a trainee a
variety of flexible ways of responding to their own private events. For example, if a staff trainer
has the thought, “Why did I get promoted? People are going to find out that I’m not really ready
for this job,” the trainer may engage in a technique that disrupts the inflexible private event that
may lead to escape-maintained behavior. For example, she might pause for a moment and
imagine that those words are written on leaves floating down a stream. Or she might repeat the
same words back in the voice of a radio announcer, in super slow motion, or in a chipmunk
voice, etc. The goal is for the staff member to engage in an alternative behavior to avoidance and
pause the escape-maintained behavior through a defusion exercise so that they in turn engage in
a more values-based behavior.
1.1.5 Self-as-context. A self-as-context repertoire of behavior involves variable and
flexible perspective taking behavior with respect to themselves and their relation to others. For
example, a staff member who may label themselves as “shy,” believing that they are not
outgoing enough to train others, in turn becomes rigid in their verbal behavior about their own
experience. This label could then lead that individual away from their long-term goals (e.g.
becoming experienced in staff training) and towards escape behaviors. A more flexible
perspective-taking repertoire would involve noticing self-judgments about shyness as one of
many different labels one could place on oneself and even noticing the act of placing labels as
just one of many different behaviors one can engage in toward oneself.
As procedures, self-as-context exercises prompt and give the individual reinforcement for
practicing looking beyond particular self-label or judgments (e.g., “shy”) and identify multiple
possible labels and descriptions of themselves. Self-as-context exercises often involve metaphors
EFFECT OF ACT TRAINING ON BST 12
for looking at oneself as a context or a place, rather than a thing. For example, “Life sometimes
feels like a game of chess. But what if you weren’t one of the pieces. What if, no matter how
good or bad of a day you were having, you weren’t the queen or the pawn. What if you were the
board?” Self-as-context exercises also involve prompting people to look from other perspectives,
such as “What if you were from a different culture, would you be considered shy?” or “How do
you think your grandmother sees you?” or “What if you were me, would you think you were
shy?” Overall, self-as-context procedures introduce variability and flexibility around how people
see themselves, and strengthen more flexible verbal behavior oriented toward oneself, such as “I
may be shy but I’m going to use BST and train this person because of my value of making a
difference.”
1.1.6 Committed action. Helping to support committed action is the purpose of the other
five components of the ACT model. As a repertoire of behavior, committed action consists of
committing to and then engaging in overt behaviors that move one in the direction of stated
values. For example, if a person states that taking care of their own health is an important value
to them, then they may make a commitment to someone they care about that they are going to
exercise at least one time per week and then actually engage in that behavior.
As a procedure, committed action interventions involve helping the individual to make
goals for specific overt behaviors they can engage in and how those behaviors connect them to
their values. Within staff training this may be seen as the senior therapist identifying and tacting
their current verbal behavior (e.g. “I don’t want to give this trainee feedback because they may
then dislike me”) and then immediately identifying values-based behaviors such as “I want to
provide quality training in ABA so that my clients can benefit and live a better life. In order to
provide quality training, I have to give constructive feedback.” Lastly, the senior therapist would
set realistic goals to target in future situations, such as “I will provide immediate constructive
EFFECT OF ACT TRAINING ON BST 13
feedback after teaching a new skill, at least five times per session that I observe a new ABA
therapist” and commit to that goal to someone else (e.g., tell their director or another senior
therapist).
The six component behavioral repertoires described above can be analyzed and addressed
separately, as was done above, but the purpose of all of them is to support committed values-
directed action. For example, if one is willing to experience difficulty (acceptance), then one can
have the opportunity to do hard things that they care about. If one contacts their values directly in
the moment (e.g., “I care more about helping kids with disabilities than I do about feeling
good”), then doing the hard work that committed action involves can actually be less aversive. If
one takes their own negative self-thoughts less seriously (defusion), then one is less likely to
rigidly follow them as rules and therefore one has more opportunity to engage in overt
committed action. In short, strengthening all of the six repertoires involved in ACT can come
together to help individuals gain more adaptive ways of responding to their own aversive private
events, in turn changing overt behavior and providing an individual with more access to the
positive reinforcement that values-directed action can bring about.
A variety of research and books have investigated the effects of ACT training on stress
and therapist skills in various clinical environments (Bond, Lloyd, Flaxman, & Archer, 2016).
Research surrounding direct service professionals has shown that their ability to implement high
quality care is often limited by workplace factors and stress (Pingo, Dixon, & Paliliunas, in
press). A study that evaluated the effects of a verbal and written performance feedback
intervention in addition to acceptance and commitment training, has demonstrated an increase in
active treatment and technical performance following the intervention (Pingo, Dixon, Paliliunas,
in press). Given that ABA practitioners are under significant levels of stress in their day to day
EFFECT OF ACT TRAINING ON BST 14
interactions with clients, the addition of having to train a new employee could add to those stress
levels, decreasing their effectiveness in training.
Research has investigated the effects of ACT training on stress and therapist skills in a
clinical psychology setting (Parkenham, 2015). Clinical psychology trainees are susceptible to
high levels of stress similar to that of behavioral therapists. Parkenham investigated how ACT
training effects stress levels as well as therapist skills and attributes. Results showed that ACT
training had benefits for both skill development, as well as personal benefits for the clinical
therapists, overall providing a strong connection between ACT processes and the clinical
trainee’s professional and personal outcomes.
A very recent study by Chancey et. al (2018), used a series of workshops to have direct
caregivers engage in mindfulness techniques, as well as to educate the participants on the
definition and purpose of mindfulness. Results showed that mindfulness techniques are effective
at improving caregiver interactions towards clients (Chancey et al., 2018). The use of committed
action techniques has been shown to increase instances of engagement with adult clients in a day
treatment program. Castro (2016) conducted a study in which direct service professionals
engaged in a series of ACT training workshops, this time engaging in exercises that focused on
work centered values (Castro, Rehfeldt, & Root, 2016). Results showed that as an outcome of
these workshops, interactions with their clients increased from an average of 11 interactions per
session at baseline to 16 interactions per session following intervention.
Previous research has shown the effectiveness of the train-the-trainer approach, as well as
the integration of a train the trainer approach to teaching staff to conduct behavioral skills
training. However, by integrating ACT into a train-the-trainer model, the aim of this study is to
give tools to therapists that will help them provide more effective training in the presence of
negative private events. As such, the purpose of this study is to apply ACT to a train-the-trainer
EFFECT OF ACT TRAINING ON BST 15
model to increase the percent per opportunity of BST use by senior therapists when training new
staff.
2.0 Method
2.1 Participants and Setting
Three individuals who worked directly with clients at an ABA clinic participated in this
study. Trainer 1 is a 50-year-old female who has worked in the field of ABA for 13 months.
Trainer 2 is a 36-year-old female who has been working in the field of ABA for more than ten
years, and trainer 3 is a 24-year-old female who has been working with the organization and in
the field of ABA for 6 years. All the participants were promoted to senior staff members around
2 weeks prior to the start of this study. The participants had not received training in how to train
new staff members prior to this study. As is common within the organization site, the staff
members were not instructed in how to train new employees until they are promoted to senior
staff. The three participants were chosen for this experiment based on their high level of
performance in executing applied behavior analytic interventions. All gave consent to be a part
of this study and agreed to train new staff. During the consent process, all participants were
informed that by participating in this study there would be no impact on their employment status,
future staff evaluations, or wages.
All sessions took place in the Learning and Behavioral Center clinic. The senior staff
received training in BST and ACT in a designated training office. All training sessions were
conducted by the same experimenter. Each of the training sessions varied in the time of day that
they were implemented, depending on participant availability, and each of the training sessions
took place outside of the staff members regular work hours.
EFFECT OF ACT TRAINING ON BST 16
2.2 Response Measurement
2.2.1 Dependent Variables. The dependent variable measured was the percent per
opportunity of behavior skills training used by senior therapists. The definition of BST was
based on a four-step model, which included: 1) the senior therapist verbally describing the skill,
2) demonstrating the skill with the client, 3) having the new therapist implement the skill with
the client, and 4) giving feedback on the trainee’s implementation of the skill with the client.
2.2.2 Data Collection. Data were collected on the percent per opportunity of BST use by
the senior therapists. During all phases, the experimenters identified if the senior therapist
verbally described, modeled, had the trainee implement, and provided feedback to the trainee on
a designated task analysis data sheet. See figure 2 for the data sheet used for data collection. An
opportunity was defined as an instance when the senior staff member began verbally describing a
skill, technique, or intervention to a trainee. For instance, if the senior staff member began to
verbally describe mand training to a new trainee, this would then be considered an opportunity
and data would begin to be collected.
2.2.3 Interobserver agreement. IOA data were collected on 35% of sessions for trainer
1, 33% of sessions for trainer 2, and 32% of the sessions for trainer 3. Measures of agreement
were calculated by dividing the total number of agreed BST use by the total number of
agreements plus disagreements and multiplied by 100. The overall inter-observer agreement
averaged 87% for data collected with trainer 1, 94% for data collected with trainer 2, and 90%
for data collected with trainer 3.
2.3 Design
For the purpose of this experiment, an ABC embedded within a multiple baseline across
participants was used. The design consisted of three phases, including baseline, behavioral skills
training, and acceptance and commitment training.
EFFECT OF ACT TRAINING ON BST 17
2.4 Procedures
2.4.1 Baseline. During the baseline condition, all participants were assigned a new staff
member to train during a client session. Each baseline session was 20 minutes long and took
place during a client session. The senior staff members were told to run their session normally
and to provide training to the staff member. None of the participants had received BST or ACT
training before this condition. No feedback was delivered by the experimenter regarding training
of the new staff member during this condition.
2.4.2 Behavioral Skills Training. At the beginning of this phase, each participant
received simulated behavior skills training with the experimenter in a 1:1 setting in which they
were trained to use BST with new staff. The experimenter utilized BST to teach the senior staff
how to implement BST themselves. See figure 3 for a flow-chart of the procedure used to train
BST with senior staff members. Each participant was given a behavioral skills training
worksheet, see figure 4 for an example. This worksheet consisted of an area for the participants
to write down the definitions of each aspect of behavior skills training as it was being verbally
described to them. The experimenter then modeled to the participant how to use BST to teach a
skill to a new staff member. In order to achieve this the experimenter acted as the senior staff
member while the senior staff member acted as the new incoming trainee. During role-play the
participant was prompted to engage with their worksheet which included an area for them to self-
identify when they were correctly implementing each step of BST. Feedback was provided,
consisting of praise for correctly implemented training techniques and constructive feedback for
incorrectly implemented techniques. This training session lasted approximately one hour but
continued until the trainee demonstrated at least 90% correct implementation of BST in role-play
with the experimenter. After the training, and on the same day as the training, the experimenter
observed participant sessions in which participants observed new trainees, as in baseline. In-situ
EFFECT OF ACT TRAINING ON BST 18
use of BST by the senior staff member to train new staff members was measured during this part
of the phase. During the in-situ use of BST, senior staff would describe a skill, model the skill
with the client, have the new staff member implement the skill with the client, and then provide
the new staff member with feedback. Feedback on the implementation of BST was not delivered
to the senior staff by the experimenter during these sessions. The experimenter positioned
themselves in such a way that they were not fully involved in the session. This positioning
served as a way to remedy the potential for the experimenter to serve as a prompt to the
participant to use BST.
2.4.3 Acceptance and Commitment Training. A one-hour ACT workshop was
implemented by and with the experimenter and senior therapist. Before beginning this training,
each participant was told that the purpose of this training was to help them to become an even
stronger trainer (the experimenter did not say that the purpose of training was to increase BST
use). Each participant filled out the Acceptance and Action Questionnaire (AAQ) prior to
training. The training began with a brief description of ACT followed by a mindfulness exercise
(see figure 5) guided by the experimenter. An exercise was then introduced in which the
participants identified their values as they relate to the workplace (see figure 6). The participants
then engaged in a values and committed action worksheet (see figure 7). The exercises used
during this training were all taken from published ACT literature and are described below.
Notice five things. This is a simple exercise that was used to train individuals to pay
attention to their sensory experience in the present moment. The participants were encouraged to
practice this exercise before their training sessions, as well as any time they were faced with
negative private events. Individuals were first asked to pause for a moment. Next, they were
asked to look around and notice five things they could see, they were then asked to notice five
things they could hear, and lastly, they were asked to notice five things they could feel in contact
EFFECT OF ACT TRAINING ON BST 19
with their body (Harris, 2007). The goal of this exercise was to strengthen the behavior of
attending to stimuli in the present moment and weaken the behavior of attending to verbal
behavior surrounding the past, future, or imagined events.
Drop the anchor. This was another simple exercise that was used to encourage
individuals to contact the present moment. In this exercise individuals were told first to plant
their feet on the floor. Next, they were told to push them down, to notice the floor beneath them,
supporting them. They were told to notice the muscle tension in their legs as they push their feet
down, to notice their entire body and the feeling of gravity flowing down through their head,
spine, and legs down to their feet. Lastly, the individuals were told to look around and notice
what they could see and hear around them, as well as notice where they were and what they were
doing. The participants were instructed to engage in this exercise during times when they were
faced with negative private events such as “I am too overwhelmed to teach a skill right now”
(Harris, 2007).
A Quick Look at Your Values. Within this exercise individuals were given a list of 60
common values. The values listed varied and it was explained to the participants that not every
value listed would be relevant to them. After looking over the values list, the participants were
asked to write a letter next to each value: “V” meaning very important, “S” meaning somewhat
important, and “N” meaning not important. The participants were instructed to ensure that they
marked at least ten of the listed values as “V” very important. After each of the items on the list
were marked with a letter the individuals were asked to go through all the items listed as a “V”
and to select the top six that were most important to them. Lastly, they were asked to write down
the six values that were most important to them. The goal of this exercise was to have the
individuals actively tact their values (Harris, 2009).
EFFECT OF ACT TRAINING ON BST 20
Willingness and action plan. The Willingness and Action Plan was an exercise that
included both committed action as well as values. It is a practice in which the participants were
instructed to write down their goal, as well as what values are underlying that goal. They were
then instructed to list the specific actions they take to achieve that goal. Additionally, they listed
the private events that they were “willing to make room for” that may occur in the process of
attempting to achieve this goal. At the end of this exercise the participants were prompted to list
useful reminders needed to achieve the goal, as well as break the goal down into smaller steps.
Lastly, the participants wrote down what the smallest, easiest step was that they could begin with
and make a committed action by writing down the time, day, and date that they will take the first
small step (Harris, 2007).
Approximately 24 hours after the ACT training, participants were again observed during
sessions in which they were responsible for training new therapists, as in the Baseline and
Behavioral Skills Training phases. Immediately before the first two sessions, the participants
were prompted via text message to read over their committed action plan. No more prompts were
given after the second session in the ACT phase. Similar to the BST condition, the experimenter
positioned herself in such a way as to not act as a potential prompt for the participant to engage
in BST. In order to assess generalization, the senior staff members were asked to train with new
clients or with new staff members that they had not previously interacted with. Trainer 1 trained
with two different incoming staff members and a new client during generalization probes.
Trainer 2 trained with two different clients, as well as a new staff member, and trainer 3 trained
with two different incoming staff members. The participants were asked to once again fill out the
AAQ after data collection had concluded.
EFFECT OF ACT TRAINING ON BST 21
2.4.4 Social Validity Measure. A social validity measure was used in this experiment in
which the senior staff members were asked to rate various questions on a scale of 1 to 5, 1 being
strongly disagree and 5 being strongly agree. Some questions included were, “I believe that this
study has improved my ability to train staff members,” “I approve of the acceptance and
commitment training exercises,” and “I care about becoming more effective at training using
behavior skills training.”
3.0 Results
The results for all participants are displayed in figure 9. During baseline, Trainer 1
engaged in behavior skills training in 0-14% of opportunities. Following the behavior skills
training an immediate effect was observed. A decrease was observed following the third session
within the behavior skills training phase. BST use remained stable at between 45-50% from
session ten to thirteen. Following session thirteen, the ACT condition was introduced. No
immediate effect was observed in BST use following the ACT workshop, however after session
fifteen behavior skills training use increased to 100% of opportunities and remained stable across
generalization probes.
Trainer 2 engaged in behavior skills training in 0% of opportunities during baseline.
Following the behavior skills training, Trainer 2 engaged in BST during 50-66% of
opportunities. Following the ninth session the ACT condition was introduced. There was an
immediate effect observed after the ACT workshop. Trainer 2 engaged in BST in 100% of
opportunities across 3 sessions during the intervention phase. During the initial generalization
probe the trainer engaged in BST in 86% of opportunities. In further generalization probes she
engaged in BST in 100% of opportunities.
During baseline Trainer 3 engaged in behavioral skills training in between 0-33% of
opportunities. An increase was seen following the behavior skills training phase when compared
EFFECT OF ACT TRAINING ON BST 22
to baseline. The data displayed a slight decreasing trend following session 10, eventually
stabilizing around 50-66% of opportunities. Following session fourteen the ACT workshop was
introduced. An immediate effect was seen subsequent to the workshop in which trainer 3 was
engaging in BST in 100% of opportunities. The data remained stable into generalization probes.
Results for the social validity measures are displayed in the table in figure 10. Overall,
the results of the social validity measure show that all participants found this training improved
their ability to train. The staff also reported that they felt more “relaxed” during training sessions
after the mindfulness and ACT training. Additionally, results from the AAQ measure can be seen
in figure 11 for all participants. Each participants score was measured before and after the ACT
workshop. For Trainer 1 a slight improvement was seen from her pre to post scores, additionally
for Trainer 2 a slight effect was seen, and for Trainer 3 a larger effect was seen in her self-report
measures specifically in areas regarding stress and anxiety.
4.0 Discussion
As the field of applied behavior analysis continues to grow, so does the need for quality
training within ABA agencies. Previous research has supported the effectiveness of train-the-
trainer models as well as behavior skills training. Train-the-trainer models have been found to be
successful in providing direct training in the field by an individual who has high levels of
experience. Behavior skills training has been shown to be highly effective at teaching new skills
to a mastery level. Acceptance and commitment training aims to train individuals to function
effectively in the presence of challenging private events. Together these aspects have the
potential to improve staff training. The purpose of this study was to investigate if the inclusion of
ACT results in increased BST use by senior staff when training new staff in an ABA clinic.
Results showed that the addition of ACT training was effective at increasing the percent per
opportunity use of BST across all participants.
EFFECT OF ACT TRAINING ON BST 23
Throughout this study, each participant received training in how to implement behavior
skills training when instructing a new staff member in various applied behavior analytic
procedures. The data showed that by providing training in BST, there was an effect on the
percent of BST use for each participant. The results indicated there was between a 50-60%
increase in BST use following the training. The purpose of this study however, was to determine
if by including exercises such as mindfulness, values identification, as well as committed action
plans if the percent of BST use would further increase. The overall results support previous
research showing that BST is effective and add to this research by suggesting that the addition of
ACT can increase the effectiveness of BST when training new staff members.
Some anecdotal observations worth mentioning were that participants reported at the end
of the study that they felt calmer during training sessions. Additionally, the experimenter
anecdotally observed that the trainer and trainee were less stressed, more relaxed, and the session
“flowed better” towards the end of the study.
Future research can extend this study by implementing ACT exercises in areas in which
behavior skills training has been found to be successful. Behavior skills training has been found
to be effective when working with parents and caregivers. Similarly, applied behavior analysis is
successful not only at the therapist level but also at the level of the family and the direct
caregiver. Acceptance and commitment training could be included into future parent training
models in order to help them engage in goal orientated behaviors as opposed to escape or
avoidance behaviors. The use of behavior skills training is taught to parents; however, parents
and caregivers are often faced with having to engage in BST or other behavior modification
techniques in the face of high stress or highly public environments. The addition of acceptance
and commitment training to the parent training model could lead to more effective and consistent
use of behavior skills training.
EFFECT OF ACT TRAINING ON BST 24
The applications of behavior skills training can go beyond that of the typically taught
skills within an ABA agency, and has been shown to be effective at teaching a variety of skills
such as abduction prevention, gun-play prevention, as well as sexual abuse prevention (Miles
&Wilder, 2009). The integration of acceptance and commitment training into areas such as these
may improve the effectiveness of training these skills. ACT has the potential for enhancing the
effectiveness and applicability of ABA across multiple domains of society. However, starting at
the point of training within an ABA clinic and showing that ACT can have positive effects at the
training level, leaves the door open for ACT to continue to integrate into other areas within an
agency and beyond.
While the results of this study provide insight into the positive effect of the inclusion of
ACT into a training model, there are several limitations worth mentioning. The study relied upon
the rate of new staff being hired. There had to be new staff who were beginning their training in
order for the senior staff to have the opportunity to train them. The various schedules of both
trainees and the senior staff members can introduce variability in the progression of the data
collection. Additionally, as data were collected during the participants already scheduled
sessions there was variability in the type of client the trainer and trainee were working with.
Some sessions included more advanced applied behavior analytic programming, while others
utilized early intervention programming. The sessions with advanced behavior analytic
programming or with a more advanced trainee presented less opportunities for BST use, and it is
possible that could have introduced additional variability into the results. However, the results
were highly consistent across participants and within phases, so it appears that the effectiveness
of ACT was sufficient to overcome any additional variability that uncontrolled aspects of the
environment may have introduced.
EFFECT OF ACT TRAINING ON BST 25
Another potential limitation was the presence of the experimenter during experimental
sessions. It is possible that the presence of the experimenter served as a prompt for the
participants to engage in behavior skills training with the new staff member. However, as with
virtually all studies on staff training that do not employ surreptitious observation (and very few
do), it is possible that the presence of observers could serve as a subtle prompt. In order to
address this, the participants were not given feedback during the observation sessions.
Additionally, the experimenter would position herself in a way that the experimenter was not
fully included into the session, and as such likely did not influence participant behavior
excessively. In addition, it was a regular part of the experimenter’s job to observe the
participants in that same setting, as that was a routine part of the experimenter’s job at the
company in which the study was conducted. In addition, the possible influence that reactivity
may have had on the participant behavior of implementing BST would likely have been present
for both baseline and BST conditions, not only the ACT condition, and yet still a substantial
improvement was observed during the ACT condition.
A final potential limitation is the lack of a component analysis regarding which
components of ACT were necessary. The current treatment included values, mindfulness, and
committed action exercises. A future component analysis could be conducted to determine which
of the components were necessary. However, it is worth noting that the majority of ACT
research includes all six components. It could be argued that this study takes a more focused
approach compared to already published ACT research. Additionally, the entire duration of the
ACT workshop was one hour, as compared to six to twelve-hour workshops commonly used in
ACT literature. It seems unlikely that there was a large amount of unnecessary ACT intervention.
This study provides initial evidence that the inclusion of ACT techniques into a train-the-
trainer model was effective at further increasing the use of behavioral skills training. This study,
EFFECT OF ACT TRAINING ON BST 26
as well as other studies incorporating ACT into staff training, represent a step toward addressing
problematic private events within the scope of practice of applied behavior analysis. With the
inclusion of ACT, training can begin to not only take care of the needs of new staff but also
address the needs of senior staff as well. As the field of applied behavior analysis continues to
grow, so will the need for quality training and this study represents a step towards helping ensure
quality training during that continued growth.
EFFECT OF ACT TRAINING ON BST 27
References
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Castro, M., Rehfeldt, R. A., & Root, W. B. (2016). On the role of values clarification and
committed actions in enhancing the engagement of direct care workers with clients with
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207.
Chancey, C., Weihl, C., Root, W. B., Rehfeldt, R. A., McCauley, D., Takeguchi, K., & Pritchard,
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adults with developmental disabilities. Journal of Contextual Behavioral Science.
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Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third
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EFFECT OF ACT TRAINING ON BST 30
Appendix

Figure 1. ACT Model of Behavior Change. (Coyne, McHugh, and Martinez, 2011).

EFFECT OF ACT TRAINING ON BST 31

Figure 2. Data Sheet

Figure 3. BST Training Procedure Flow-Chart

Training Model Data
Date: ________ Opportunity Data Opportunity Data Notes:
Time in: ______ Program/Bx: Program/Bx:
Time Out: _____
Experimenter: ________ V M RP FB V M RP FB
Phase: BL BST ACT Program/Bx: Program/Bx:
Frequency Score V M RP FB V M RP FB
1
2 Program/Bx: Program/Bx:
3
4 V M RP FB V M RP FB
5
6 Program/Bx: Program/Bx:
7
8 V M RP FB V M RP FB
9
10 Program/Bx: Program/Bx:
11
12 V M RP FB V M RP FB
13
14 Program/Bx: Program/Bx:
15
16 V M RP FB V M RP FB
17
18 Program/Bx: Program/Bx:
19
20 V M RP FB V M RP FB
Frequency: ____________ %/opportunity: ________ %/opportunity: ________
Participant: Session # IOA:
EFFECT OF ACT TRAINING ON BST 32

Figure 4. BST Worksheet

EFFECT OF ACT TRAINING ON BST 33

Figure 5. Mindfulness worksheets

EFFECT OF ACT TRAINING ON BST 34

Figure 6. Quick look at your values

EFFECT OF ACT TRAINING ON BST 35

Figure 7. Willingness and Action Plan

EFFECT OF ACT TRAINING ON BST 36

Figure 8. Social Validity Survey

EFFECT OF ACT TRAINING ON BST 37

Figure 9. Percent per Opportunity of BST across Sessions

Figure 10. Social Validity Results
EFFECT OF ACT TRAINING ON BST 38

Figure 11. AAQ Results

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Asset Metadata

Creator Little, Alexandra (author)

Core Title Using acceptance and commitment training to enhance the effectiveness of behavioral skills training

School College of Letters, Arts and Sciences

Degree Master of Science

Degree Program Applied Behavior Analysis

Publication Date 04/24/2019

Defense Date 04/24/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag acceptance and commitment therapy,acceptance and commitment training,Applied Behavior Analysis,behavior skills training,OAI-PMH Harvest,Staff Training

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Contributor Electronically uploaded by the author (provenance)

Advisor Tarbox, Jonathan (committee chair), Cameron, Michael (committee member), Harris, Jennifer (committee member), Manis, Frank (committee member)

Creator Email alexandralittle23@gmail.com,littlea@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-143172

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