Summer et al. (2021) PDF - The role of the behavior analyst on interprofessional mental health teams

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/354536961 The role of the behavior analyst on interprofessional mental health teams: opportunities for collaboration and enhancing patient care Article in Journal of Interprofessional Care...

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/354536961 The role of the behavior analyst on interprofessional mental health teams: opportunities for collaboration and enhancing patient care Article in Journal of Interprofessional Care · September 2021 DOI: 10.1080/13561820.2021.1969345 CITATIONS READS 5 2,319 4 authors: Jane Summers Louis Busch SickKids Centre for Addiction and Mental Health 23 PUBLICATIONS 1,103 CITATIONS 18 PUBLICATIONS 26 CITATIONS SEE PROFILE SEE PROFILE Milena Kako Catherine Lau Centre for Addiction and Mental Health Centre for Addiction and Mental Health 2 PUBLICATIONS 89 CITATIONS 2 PUBLICATIONS 9 CITATIONS SEE PROFILE SEE PROFILE All content following this page was uploaded by Louis Busch on 12 April 2022. The user has requested enhancement of the downloaded file.  1 Dialectical B The Role of the Behaviour Analyst on Interprofessional Mental Health Teams: Opportunities for Collaboration and Enhancing Patient Care Jane Summers¹, Louis Busch², Milena Kako3, Catherine Lau² 1 Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada ²Centre for Addiction and Mental Health, Toronto, Ontario, Canada 3 Launch Behavioural Health, Toronto, Ontario, Canada This is an Accepted Manuscript of an article published by Taylor & Francis in Journal of Interprofessional Care on September 12, 2021, available online: http://www.tandfonline.com/doi.org/10.1080/13561820.2021.1969345  2 Abstract Patients living with mental illness have needs that span a range of professional disciplines, settings and service systems. These needs are best addressed through interprofessional collaboration. Behaviour analysts can play a valuable role in enhancing patient care as part of the interprofessional mental health team. We provide information about the field of applied behaviour analysis and its contribution to the assessment and treatment of patients living with mental health and substance use challenges. We outline how behaviour analysts are trained and touch upon the practice of behaviour analysis in North America and beyond. We describe collaborative relationships with other mental health professionals and, as an example, review the role of the behaviour analyst on interprofessional teams in our mental health and addiction teaching hospital in Canada. We highlight some of the challenges faced by behaviour analysts working in the mental health field and offer suggestions to increase their profile and opportunities for collaboration in clinical programs. Keywords: interprofessional collaboration, applied behaviour analysis, mental health, substance use Running Title: Behaviour analyst and mental health teams  3 Introduction Patients living with mental illness have needs that span a range of professional disciplines, settings, and service systems. Mental health disorders are a world-wide problem associated with extraordinary social and economic costs to individuals, families, systems of care, and society. At any given time, approximately one in five adults has a diagnosed mental illness, which causes high rates of disability, adds greatly to the cost of healthcare, and generates huge losses in productivity (Layard, 2016). The co-occurrence of substance use disorders compounds these challenges and further complicates clinical formulations while creating obstacles to healthcare accessibility (Walker & Druss, 2016). A growing body of research suggests that the needs of these complex patients are best addressed through the provision of patient-centred, interprofessional collaboration, which makes use of the expertise of different healthcare professionals who work together towards a shared goal of providing high quality patient care to improve outcomes (D’Amour et al., 2005; Zwarenstein et al., 2009). Important competencies for effective interprofessional collaboration, as identified by front-line healthcare providers, include knowledge of and appreciation for backgrounds, roles and responsibilities of team members, and the ability to communicate clearly and flexibly in ways that are understood by patients and fellow professionals (Suter et al., 2009). Additional competencies for effective interprofessional collaboration include an understanding of teamwork and team dynamics, a willingness to work outside one’s own professional comfort zone, and to appreciation and accommodation of diverse points of view in a respectful and constructive manner (Arredondo et al., 2004; Canadian Interprofessional Health Collaborative [CIHC], 2010). Interprofessional collaboration is an evolving process that occurs in diverse  4 contexts and can be associated with a number of challenges (Reeves et al., 2017). Although further research is necessary, emerging evidence from systematic reviews of empirical studies indicates that interprofessional collaboration can have a positive impact on the delivery of health-related services and patient outcomes (Lutfiyya et al., 2019; Zwarenstein et al., 2009). Behaviour analysis has its genesis in the treatment of mental health challenges in psychiatric care settings (Ayllon & Michael, 1959), and has been an applied discipline for more than 50 years (Baer et al., 1968). Behaviour analysts are not well-known to many interprofessional mental health teams but play a valuable role in enhancing patient care. In this article, we provide information about the field of applied behaviour analysis and its contribution to the assessment and treatment of patients living with mental health and substance use challenges. We outline how behaviour analysts are trained and touch upon the practice of behaviour analysis in North America and beyond. We describe collaborative relationships with other mental health professionals and review the role of the behaviour analyst on interprofessional teams in our mental health and addiction teaching hospital in Canada. Finally, we highlight some of the challenges faced by behaviour analysts working in the mental health and substance use disorder field and offer suggestions to increase their profile and opportunities for collaboration in clinical programs. Background on Behaviour Analysis Applied Behaviour Analysis (ABA) evolved from operant-behavioural psychology and is the application of the science of behaviour to address problems of social or interpersonal importance (Baer et al., 1968). Contemporary behaviour analysis is pragmatic and contextualistic in nature; that is, behaviour is understood as a function of its current and historical contexts, including biological and health factors (Busch et al., 2020). ABA uses findings from basic  5 research on the principles of learning and behaviour to develop interventions that have practical benefits for people of all ages and circumstances by addressing their real-life problems and optimizing their physical, emotional, and social well-being. Assessments within ABA aim to identify the environmental events that are responsible for the maintenance of targeted behaviours over time, including events that precede and follow the behaviour, to develop effective (i.e., function-based) interventions. Functional analysis methods can be used in clinical contexts to identify reinforcers that maintain problem behaviour (Iwata & Dozier, 2008). Behaviour analytic research and clinical work share a focus on behaviour change at the level of the individual and preferentially employ single-subject experimental designs rather than group designs to evaluate the effectiveness of treatment. While ABA is most often associated with addressing the needs of individuals with developmental disabilities and autism spectrum disorder, it can be applied to a wide range of populations and challenges, including the skill deficits and potentially harmful behaviour that often co-occur with mental health and substance use problems (M.T. Harvey et al., 2009). Applied behavior analysis is a distinct professional discipline with dedicated graduate- level university training programs, independent certification and licensing bodies, and local and international professional associations. An autonomously practicing behaviour analyst completes a graduate degree from an accredited institution (at the Master or Doctoral level), typically in psychology, education, or applied behaviour analysis (Carr & Nosik, 2017); engages in extensive supervised practice; passes a written examination; and demonstrates a commitment to continuing education in ethics, supervision, and clinical practice (Behavior Analyst Certification Board, 2012). Required graduate-level coursework covers ABA foundational  6 knowledge in the theory and practice, ethics and professional conduct, research methods, measurement, assessment, and intervention. As of October 2020, there were over 42,000 board certified behaviour analysts worldwide. The vast majority of practitioners of behaviour analysis reside in North America (mainly in the United States, with approximately 1,500 certified behaviour analysts in Canada), most often providing ABA-based interventions to young children with ASD (A.C. Harvey et al., 2010). Certified behaviour analysts are found in 84 countries across five continents with 89 educational institutions outside the US and 668 within North America providing ABA training (N. T. Martin & Carr, 2020). On a global level, the Association for Behavior Analysis International (ABAI) has more than 9,000 members worldwide with more than 30 affiliate chapters operating outside of North America. ABAI hosts training events and special interest groups that deal with issues of interest to members of the behaviour analytic community in the fields of autism, behavioural gerontology, behavioural medicine, forensic behaviour analysis, and pediatric feeding disorders, to name a few. Method For this article, we conducted a targeted review of the literature using electronic databases of peer-reviewed journals. Databases included but were not limited to PsychInfo, Web of Science, EBSCO, Wiley and Google Scholar. Relevant journals (e.g., Journal of Interprofessional Care, Journal of Applied Behavior Analysis, Behavior Analysis in Practice) were searched as well. Searches were carried out using combinations of identified terms (e.g., interprofessional collaboration, applied behaviour analysis, mental health, substance use, nursing, health psychology). Results  7 Clinical Populations and Areas That Can Benefit From the Services of a Behaviour Analyst A behaviour analytic approach is transdiagnostic, individualized, and strengths-based. It emphasizes skill development while treating challenging behaviours to minimize impairment, maximize functional abilities, and promote rehabilitation and recovery. Comprehensive ABA approaches are best known as treatments for addressing learning and skill deficits in young children with autism spectrum disorder (Eldevik et al., 2009). Approaches incorporating behavioural principles can also be applied to a wide range of mental health conditions, including depression (Ekers at al., 2014), anxiety disorders (Reynolds et al., 2012), and substance use disorders (Farronato et al., 2013). They are also used to address adaptive skill deficits and behavioural challenges associated with intellectual and developmental disabilities (Neidert et al., 2010), schizophrenia (Dixon et al., 2010), dementia (Buchanan et al., 2011), and acquired brain injury (Heinicke & Carr, 2014). Collaborations Between Behaviour Analysts and Other Mental Health Professionals Behaviour analysts have been collaborating with other health professions for more than 60 years to improve the quality of life of individuals living with mental health challenges. Behaviour analysts bring a unique contextual lens to the interprofessional team by focusing on the relationship between behaviour and environmental events: a functional approach that permits integration within the work of most other disciplines (Busch et al., 2020). Collaborating with Mental Health Nurses One of the earliest applications of behavioural principles to improve the lives of patients with mental illness was with psychiatric nurses who were trained as “behavioural engineers” and utilized reinforcement-based programs (Ayllon & Michael, 1959). Mental health nurses often play a key role on teams that respond to psychiatric and behavioural crises in mental health and  8 medical settings (Choi et al., 2019). Response teams use crisis intervention and recovery-focused approaches that are based on values and practice guidelines shared by behaviour analysts (Lim et al., 2019). Behavioural interventions such as graduated exposure and reinforcement can be employed by nurses in collaboration with behaviour analysts to help patients manage their fear of needles (Cromartie et al., 2014) that can interfere with depot injections of psychotropic medication or blood draws to monitor medication levels and side effects. Collaborating with Psychiatrists Behavioural pharmacology brings together the disciplines of behaviour analysis and pharmacology to study the effects of medications on behaviour (van Haaren, 2016). Prescribing psychotropic medication is the domain of the psychiatrist. However, behaviour analysts play a valuable supporting role on the interprofessional team by providing the psychiatrist with ongoing objective measurements on the effects (both intended and unintended) of psychotropic medication on specific target behaviour (Weeden et al., 2017). By using functional analysis methodology prior to and following medication adjustments, the behaviour analyst is able to provide information about behavioural responses (e.g., changes in rate) to psychotropic medication as well as possible interactions between medication and behavioural functions (Cox & Virues-Ortega, 2016). Data can also be collected about other key indicators of medication effectiveness, including reduction in the use of restrictive measures (i.e., pro re nata [PRN] usage, mechanical restraints) to manage symptoms of mental illness and assist with clinical decision making. Collaborating with Allied Health Professionals Behaviour analysts and other disciplines on the mental health team provide therapies that can be combined with drug treatment to enhance clinical outcomes. Effective collaboration  9 requires an appreciation for the different contributions of team members as well as opportunities to evaluate the impact of all interventions collectively. The behaviour analyst works with team members to design and implement systems to track target behaviours and afterward present individualized data in visual (graphic) format for all to use when evaluating treatment effectiveness. Behaviour analysts also obtain information about the acceptability of drug treatments and clinical therapies from the point of view of the patients, their substitute decision makers, and staff to assist the team in identifying which approaches are likely to be valued and followed over time (“social validity”; Wolf, 1978). Each discipline on the mental health team is guided by their specific standards of practice, code of ethics, and approaches to assessment and treatment, which may be at odds at times. However, there are many areas of common ground in training and/or practice among the allied disciplines. For instance, behaviour analysis traces its roots to operant-behavioural psychology laboratories, with many behaviour analysts graduating from psychology programs. Clinical and educational psychologists for their part may undergo additional specialized training to become certified in behaviour analysis, but this is not common (Dillenburger et al., 2014). Health psychologists specialize in understanding the relationship among psychological factors, health, and illness (P. R. Martin et al., 2014) and use psychological techniques to increase motivation and self-efficacy and decrease negative or unrealistic thoughts. Behaviour analysts focus on manipulating antecedent and consequent variables as they apply to health-related choices and activities and use behaviour analytic principles and procedures such as goal setting and data collection, stimulus control and contingency management (Normand et al., 2015). Although the two fields of behaviour analysis and psychology tend to function independently, many psychological treatments are derived, at least in part, from the basic principles of operant  10 and respondent learning theories (e.g., Cognitive Behaviour Therapy, Dialectical Behaviour Therapy, Acceptance and Commitment Therapy). Behaviour analysts are likely to prefer direct measures of observable behaviour over standardized tools because the latter measure internal states via self-report. They also typically apply single-subject research designs over group-designs when evaluating treatment effectiveness and seek explanations for behaviour by examining their relationship to environmental variables rather than looking to internal phenomena. However, contemporary behaviour analysis does not exclude the role of language, cognition, emotion, or biology as sometimes incorrectly assumed (Brown & Gillard, 2015). In fact, behaviour analytic perspectives have contributed important theoretical, basic, and applied work to understanding the role of these processes in human psychopathology and its treatment (Hayes et al., 2001). Psychological treatments and behaviour analytic procedures can be effectively integrated to treat mental health and behavioural disorders, with each discipline respecting and benefitting from the other’s training and expertise. Practitioners of applied behaviour analysis and occupational therapy both emphasize utilizing strengths-based approaches, recognize the importance of social and environmental variables and value the patient’s perspective and involvement in the therapeutic process (Welch & Polatajko, 2016). Assessments regarding a patient’s motivation and preferences may be of benefit to both disciplines as they work together to create a collaborative therapeutic plan (Whiting & Muirhead, 2019). Applied behaviour analysis and social work also overlap in significant ways. Both clinical disciplines are trained to use single-subject research designs to evaluate the impact of clinical interventions, recognize that an individual’s behaviour and the  11 social environment interact in a reciprocal manner, and address problems of social and adaptive relevance to improve functioning (Thyer, 1999). Specific Applications of ABA in Mental Health Settings Reducing the use of seclusion and restraint Restrictive/intrusive procedures such as seclusion and restraint are used in inpatient settings to maintain safety and prevent further harm, but their use can produce unintended consequences (such as physical injury and psychological trauma) and raises a host of ethical issues (Huckshorn, 2006). At a systems level, there is strong pressure to reduce and if possible prevent the use of seclusion and restraint through changes in policy, culture, and staff education and support. Behaviour analysts contribute to a shared understanding of the conditions that give rise to a patient’s high-risk behaviour and design interventions to minimize or prevent high-risk behaviour while promoting the development of prosocial skills. Secure Recovery Individuals living with severe mental illness that come into contact with the law face unique challenges, as the processes of recovery and risk mitigation can clash. On forensic mental health teams, behaviour analysts work with their colleagues to address risk-related behaviours like substance use, medication non-compliance, and aggression and use contingency management approaches such as token economies to teach recovery-oriented skills that include self-care and emotional regulation (Pritchard et al., 2018). Medication and Treatment Adherence Partial or total non-adherence with medication and other forms of prescribed treatment poses a major challenge for patients with severe mental illness and can lead to poorer outcomes along with increased risks of relapse and hospitalization (Farooq & Naeem, 2014). Reasons for  12 non-adherence are complex and call for interventions that are individualized to address the patient’s specific circumstances (Kreyenbuhl et al., 2016). Medication adherence is especially difficult to monitor in less controlled, more naturalistic settings. Low and high tech environmental approaches that use behavioural principles by prompting medication adherence and/or providing adherence feedback may be helpful. Reinforcement-based (contingency management) approaches may also be beneficial, such as providing financial incentives for complying with depot injections and points earned for attendance at therapeutic groups (Guinart & Kane, 2019). Health Promotion Mental illness and physical diseases often occur together and the link can be bi- directional. Approximately one-third of people with mental illness are at increased risk of developing significant physical health challenges, such as cardiovascular disease, that can have a negative impact on their quality of life and reduce their life expectancy (Walker & Druss, 2016). Physical health challenges can also be associated with mental illness, such as in chronic pain and multiple health problems predicting depressive symptoms (Sharpe et al., 2017). Behaviour analytic interventions can be helpful for addressing issues concerning health and fitness by incorporating several key elements, including environmental arrangements, goal setting, and the provision of incentives and feedback (Normand et al., 2015). Because improving physical health can result in reductions in psychiatric symptoms, the collaborating behaviour analyst can play an important role in supporting patients to adopt and maintain healthier lifestyle behaviours. Substance Use Disorders High rates of comorbidity exist between mental illness (such as mood and anxiety disorders) and substance use disorders (illicit drug and alcohol dependence and abuse). Various  13 substance use and addictive disorders can be viewed as operant behaviour that is maintained and modified by consequences (Bigelow & Silverman, 1999). Behavioural therapies for addiction with strong empirical evidence include contingency management (provision of incentives/rewards) and behavioural skills training (Silverman et al., 2008). Contingency management is the most widely used ABA technique in addiction treatment and is based on principles of behavioural pharmacology and operant conditioning. It has demonstrated effectiveness in increasing abstinence, improving adherence to treatment medication, and increasing retention in treatment (Dutra et al., 2008.). The Role of the Behaviour Analyst on the Interprofessional Mental Health Team: A Canadian Example In our mental health and addiction teaching hospital in Canada, mental health teams are interprofessional in nature. Core team members often consist of the psychiatrist, clinical psychologist, psychiatric registered nurse, social worker, occupational therapist, recreational therapist, and behaviour analyst. Additional members can include the pharmacist, dietician, peer support worker, personal support worker, and developmental service worker. Although behaviour analysts got their start in the hospitals working with patients with autism and/or developmental disabilities, their role expanded over time, and they now collaborate with team members in inpatient and outpatient programs that provide acute and chronic mental healthcare to a range of populations including the elderly, patients with serious mental illness, individuals with brain injury, and those in the forensic system. Case Report As an example of interprofessional collaboration at our hospital, a 26-year-old man living with comorbid diagnoses of 22q11.2 deletion syndrome, schizophrenia, and intellectual disability  14 underwent assessment and treatment. During the patient’s extended stay on forensic mental health inpatient units, the interprofessional mental health team worked to stabilize his mental health symptoms, identify an effective medication regime in the treatment of psychosis, treat related medical issues such as gastrointestinal dysfunction, and reduce the frequency of contextually inappropriate behaviour while teaching alternative social and adaptive living skills conducive to discharge and safe community living. In addition to contributing an assessment of environmental variables, which were related to behavioural disturbances, the behaviour analyst worked with nurses, general practitioners, and psychiatrists to evaluate the impact of psychopharmacological interventions on the patient’s mood, psychotic symptoms, and gastrointestinal health. By operationally defining mood states, psychotic symptoms, and indications of side-effects, the behaviour analyst was able to generate time-series graphs of behavioural, psychiatric, and biomedical targets with phase lines identifying new interventions or changes to existing protocols. Together, the team could then review trends and determine the appropriate next steps in treatment. At the point of discharge, the behaviour analyst, social worker, nurse, and occupational therapist worked together to ensure the patient’s smooth transition to the community. Discussion Working as a behaviour analyst on an interprofessional mental health team brings opportunities as well as challenges. Opportunities include the chance to learn from and work alongside professionals from different disciplines, with the common goal of providing high quality patient care and improving outcomes (D’Amour et al., 2005; Zwarenstein et al., 2009). A behaviour analytic lens brings greater sophistication and rigor to the process of selecting, defining and observing target behaviours as well as implementing and evaluating the impact of  15 behavioural and non-behavioural (e.g., medical and pharmacological) interventions (Li & Poling, 2018; Poling & Cleary, 1986). Behaviour analysts also contribute to government and organizational policies and procedures aimed at accurately measuring and reducing the use of restrictive procedures in healthcare and social service settings (Reed et al., 2013). Challenges for behaviour analysts include working in systems of care that are often dominated by medical models and an underappreciation for single-subject research designs despite the fact they contribute robust data to assist in clinical decision making (e.g., Kazdin, 2011) and offer practical and economical advantages over large group interventions. There can also be a lack of appreciation for the distinction between the discipline of applied behaviour analysis and the use of applied behaviour analytic principles and practices by providers who do not meet established standards for education and training (Kelly et al., 2019). Employment opportunities may be scarce, so effective messaging is needed to educate mental health professionals and funders about the value of behaviour analytic services (LeBlanc et al., 2012), including the advantages of hiring behaviour analysts with their specific competencies and use of methods like single-subject research designs that offer a rigorous way to evaluate the impact of interventions on healthcare outcomes. Behaviour analysts are currently licenced healthcare professionals in most jurisdictions in the US, but less frequently so in other countries. In Canada, regulation of behaviour analysts is proceeding in one province and being proposed in a number or other provinces. Policymakers in countries that employ behaviour analysts should view professional regulation as an opportunity to protect the public and improve upon the quality and oversight of a rapidly growing profession. More than a half century ago, behaviour analytic approaches were used in the treatment of severe mental illness, such as reducing psychotic speech and increasing appropriate social  16 responses in people with schizophrenia (Wong, 2006). More recently, the focus of behaviour analysis shifted to supporting individuals with autism spectrum disorder and developmental disabilities, resulting in viable and rewarding careers for many behaviour analysts. To regain a foothold in mental health, behaviour analysts need to demonstrate a willingness to collaborate with other disciplines, to learn more about topics relating to mental health and psychotropic medication, and to find ways to effectively promote the collection and utilization of behavioural data and treatment procedures to inform clinical decision making (Li & Poling, 2018). Of course, as happened in our case, other professionals also need to see the value of adding behaviour analysts to their interdisciplinary teams. Behaviour analysts contribute an understanding of the learned aspects of mental illness and recovery and can be valuable members of an interprofessional mental health team. Their skills in assessment and treatment can be expanded to include underserved but growing clinical populations such individuals with dementia and acquired brain injury. We hope the information presented in this article will encourage service providers beyond (and also within) the United States and Canada to consider adding behaviour analysts to their workforce and in doing so, reap the full benefits of all they have to offer. Declaration of Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.  17 References Arredondo, P., Shealy, C., Neale, M., & Winfrey, L. (2004). Consultation and interprofessional collaboration: Modeling for the future. Journal of Clinical Psychology, 60(7), 787-800. doi:10.1002/jclp.20015. Ayllon, T., & Michael, J. (1959). The psychiatric nurse as a behavioral engineer. Journal of the Experimental Analysis of Behavior, 2(4), 323-334. doi:10.1901/jeab.1959.2-323. Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91-97. doi:10.1901/jaba.1968.1- 91. 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