Slim and Reuter-Yuill (2021) A Behavior-Analytic Perspective on Interprofessional Collaboration PDF

Behavior Analysis in Practice (2021) 14:1238–1248 https://doi.org/10.1007/s40617-021-00602-7 DISCUSSION AND REVIEW PAPER A Behavior-Analytic Perspective on Interprofessional Collaboration Lina Slim 1,2 & Lilith M. Reuter-Yuill 3,4 Accepted: 19 May 2021 / Published online: 20 July 2021 #...

Behavior Analysis in Practice (2021) 14:1238–1248 https://doi.org/10.1007/s40617-021-00602-7 DISCUSSION AND REVIEW PAPER A Behavior-Analytic Perspective on Interprofessional Collaboration Lina Slim 1,2 & Lilith M. Reuter-Yuill 3,4 Accepted: 19 May 2021 / Published online: 20 July 2021 # Association for Behavior Analysis International 2021, corrected publication 2021 Abstract Collaborative service delivery models have gained considerable popularity in health care, education, and clinical settings. Despite the unique opportunity that this new popularity provides for the dissemination of applied behavior analysis, the majority of practicing behavior analysts have received little or no formal professional development on how to participate in teams with nonbehavioral colleagues. The purpose of this article is to elucidate the larger movement toward collaborative service delivery with an emphasis on interprofessionalism. The four core competency domains presented by the Interprofessional Education Collaborative (IPEC) Framework are interpreted through a behavior-analytic lens. This article is an initial attempt to operationalize constructs commonly associated with interprofessional educational and collaborative practices including (but not limited to) cultural sensitivity and responsiveness, cultural humility and reciprocity, empathy, and compassion. Keywords Collaboration. Interprofessionalism. Interprofessional education. Interprofessional practice. Interprofessional education collaborative. Interprofessional collaborative practice Since the national credentialing of behavior analysts was professionals with differing ideologies, professional ethics, established by the Behavior Analyst Certification Board and approaches to intervention (Brodhead, 2015; Cox, 2019; (BACB) in 2000, the number of credentialed providers and LeBlanc et al., 2012). As practitioners of applied behavior the accessibility of important behavior-analytic services have analysis, we need to be cognizant that ineffective professional dramatically increased. The benefits of applied behavior anal- collaboration can lead to interpersonal friction (i.e., hostile ysis are well recognized for individuals with autism spectrum competition, communication breakdowns, strained profes- disorder (BACB, 2020) and in other areas of social signifi- sional relationships, etc.) that can damage our credibility with cance (LeBlanc et al., 2012). Consequently, practitioners of colleagues and clients. Most importantly, however, evidence applied behavior analysis will likely find themselves working suggests that poor collaboration may also negatively impact closely with nonbehavioral colleagues such as speech- the treatment process and clinical outcomes for clients language pathologists, occupational therapists, teachers, phy- (Dillenburger et al., 2014; Gerenser & Koenig, 2019). sicians, and so on in their clinical work. This concern over effective collaboration and relationship Although there are many potential benefits to cross- building should not be viewed as an abstract concept. Taylor disciplinary collaboration, practicing behavior analysts may et al. (2018) noted that behavior analysts “do not always establish experience barriers to working effectively among and sustain collaborative and caring relationships” (p. 2). These observed deficits can negatively impact treatment delivery and client outcomes (Taylor et al., 2018) and attenuate opportunities * Lina Slim for disseminating the applied science of behavior analysis. [email protected] Despite the ubiquity of cross-disciplinary teams and the high cost of ineffective interprofessional collaboration, behavior an- 1 ASAP—A Step Ahead Program, LLC, 33 Joss Way, alysts report little to no professional development on how to Millington, NJ 07946, USA successfully work with professionals from outside the field 2 ABA Online Program, The Chicago School of Professional (Kelly & Tincani, 2013; Tincani, 2013). The purpose of this Psychology, Chicago, IL, USA article is to elucidate the larger movement of collaborative ser- 3 Department of Psychology, Western Michigan University, MI vice delivery by providing practitioners with a historical con- Kalamazoo, USA text and description of common collaborative models with an 4 Comprehensive Speech and Therapy Center, Jackson, MI, USA emphasis on interprofessionalism. A behavior-analytic Behav Analysis Practice (2021) 14:1238–1248 1239 interpretation of the leading guidelines on interprofessionalism detailed discussion of how the competencies could be consid- by the Interprofessional Education Collaborative (IPEC) ered part of the professional development of behavior ana- Framework and related terms is entertained. lysts, it is first important to understand the forms that collab- oration might take. These models are best conceptualized on a continuum from static, independent silos to dynamic, interde- Collaborative Service Delivery Models pendent, and interactive systems. Collaborative service delivery has been a topic of interest in Multidisciplinary Model medicine for several decades, with growing interest across habilitation and rehabilitation services such as speech- The oldest teamwork model is the multidisciplinary approach language pathology, social work, occupational therapy, phys- that emerged following the team evaluation legislative man- ical therapy, and behavioral health (World Health dates. Assessment and treatment are discipline oriented. Organization [WHO], 2010). A variety of organizations have Professionals are self-reliant and individually responsible for investigated and sought to promote collaborative service de- the therapeutic activities that pertain to their discipline. livery models, including the Institute of Medicine (IOM, now Providers act independently and make autonomous decisions called the National Academy of Medicine and the Institute for for treatment programming. Collaboration occurs by sharing Healthcare Improvement (IHI, 2008); IOM Committee on information regarding their plan with other team members Quality of Health Care in America, 2001). Both organizations (Boyer & Thompson, 2013). Group consensus is not required have done considerable work to create criteria to guide inter- for treatment decisions, and families are not regarded as inte- professional collaborative service delivery. gral team members. Professionals may be colocated, but there To address the rising cost and global shortage of health is a minimal exchange of information or interaction between care, the WHO built on these efforts with its Framework for disciplines (Rossetti, 2001). Catlett and Harper (1992) sug- Action on Interprofessional Education and Collaborative gested that this is the easiest model to implement as it main- Practice (WHO, 2010). Although this framework focuses on tains a high level of professional autonomy. Professional in- modifications to education and health policies to foster inte- dependence may expedite expert evaluation and decision grated health and education and more effectively address making; however, the lack of information exchange and fragmented and unmet health needs while improving out- shared goal setting may lead to disjointed treatment plans comes, it also provides powerful language to discuss this topic and less productive treatment sessions that lack continuity. and several suggestions for improved interprofessional educa- The multidisciplinary approach also creates treatment frag- tion and greater adoption of interprofessional collaborative mentation that may cause an extra burden to families practices (IPCP/IPP). (Woodruff & McGonigel, 1988). Inspired by the WHO’s framework and the work by the IOM, the IPEC, a collaborative of national organizations Interdisciplinary Model representing various health care professions (i.e., American Association of Colleges of Nursing), published its Core An interdisciplinary approach represents a more cooperative Competencies for Interprofessional Collaborative Practice framework. Independent, profession-specific roles are main- (IPEC, 2016; IPEC Expert Panel, 2011). The IPEC tained during the assessment period, and a formal meeting is Framework was developed specifically for health care profes- established to exchange assessment findings. Professionals sional schools to use as a guide in their curricular develop- work as a cohesive unit to make collaborative decisions on ment. This framework is based on “a vision of interprofession- treatment plans and intervention targets. Each team member al collaborative practice as key to the safe, high quality, ac- brings their discipline-related information and contributes to cessible, patient-centered care desired by all” (IPEC Expert the overall “big picture” based on their own strengths and Panel, 2011, p. i) and a “catalyst for improving team-based challenges (Foley, 1990). patient care and enhancing population health outcome” The interdisciplinary intervention model represents the (University of New Mexico Health Sciences Center, n.d.). middle position on the collaboration continuum. There is a In 2016, the IPEC revised the core competencies for IPCP/ presupposition of interaction between the disciplines. Formal IPP to reflect changing health care needs. The IPEC focus was opportunities for information exchange are established, and on implementing the Triple Aim, as well as “the Patient role boundaries are more relaxed (Catlett & Harper, 1992; Protection and Affordable Care Act in 2010” (IPEC, 2016, Fewell, 1983). Caregivers anecdotally report feeling more in- p. 4). Whereas the IPEC work outlines competencies needed volved in therapy planning and attribute this to a stronger to build IPCP/IPP, there are several working models of col- relationship with the service provider (Woodruff & laboration, including multidisciplinary, interdisciplinary, McGonigel, 1988). However, this model also has the potential transdisciplinary, and interprofessional. Before we go into a for misunderstandings, competition, and lack of coherence, 1240 Behav Analysis Practice (2021) 14:1238–1248 and different disciplines may generate opposing recommen- team members, TD requires a high degree of cooperation dations that lead to undesirable clinical outcomes for successful implementation (King et al., 2009). (Dillenburger et al., 2014). Nevertheless, the interdisciplinary Although there is consensus that a high degree of commu- model strives to foster productive information exchanges and nication, collaboration, and support is necessary (Boyer & collaborative environments. This model requires a robust set Thompson, 2013; Foley, 1990; King et al., 2009), the pro- of interpersonal skills to facilitate successful interactions and cesses to plan effective implementation of TD collaborative prevent boundary infringement and frustration. practices are not in place. Technological descriptions and performance standards such as quality, quantity, and Transdisciplinary Model timeliness may enable replication and increased adoption of collaborative service delivery models. The transdisciplinary model (TD) is much more progressive than the multidisciplinary and interdisciplinary models and is well recognized and adopted in the area of early intervention. Interprofessional/Interprofessionalism TD is a highly involved system that includes a liberalization of professional roles and scope of practice. The degree of service Farrell (2016) noted that interprofessionalism is a process by coordination at this level requires commitment from each which professionals from different disciplines effectively en- team member at all stages of assessment and treatment to gage in collaborative practice that is fostered by establishing a teach, learn, and work together (Foley, 1990). According to foundation of shared ethical standards and values and by em- King et al. (2009), there are three essential features of TD: bracing a vision of an “inclusive” clinical culture (Farrell, arena assessment, role release, and intensive ongoing interac- 2016). An inclusive culture is one that is open to, respects, tion between group members: and welcomes a team approach by embracing the contributions of each member of the professional team. 1. Arena assessment is an alternative to discipline-specific Légaré et al. (2011) offered key concepts for assessment practices. In arena assessment, one provider interprofessionalism and shared decision making that facilitates the assessment process while other team mem- enhance IPCP/IPP, including exchange of information, bers observe the interaction to obtain information (Boyer clarification of values and preferences, openness to options, & Thompson, 2013). This approach has some critical ad- and preferred and actual choices. Légaré et al. (2011) stated vantages. First, as all professionals observe the same be- that by effectively working together in a team-based and havior, that shared sample of behavior creates a standard- patient-centered manner, the team develops a comprehensive ized baseline observation for ongoing progress monitor- and integrated collaborative practice to meet the needs of their ing. Second, arena assessment minimizes disconnects or clients. Interprofessionalism has been associated with (a) an disagreements that may occur with independent observa- increased quality of health care delivery; (b) improved client tions. Finally, this approach creates an opportunity for health outcomes; (c) an enhanced work life of care providers, shared vocabulary and information exchange (Boyer & as well as strengthened partnerships with professionals, fam- Thompson, 2013; Foley, 1990). ilies, and stakeholders; and (d) an optimized cost of care 2. Role release is another characteristic of the TD model and (Berwick, 2019; Berwick et al., 2008; Bodenheimer & occurs when members of the team release a component of Sinsky, 2014). One critical component of interprofessionalism their discipline-specific services to a single provider on is a unified conceptual framework of shared ethical principles the treatment team who will provide all direct services to that members of an inter- or multidisciplinary team adhere to the family. This professional is supported by the other in interprofessional practice. These agreed-upon principles team members through training, information exchange, provide a code of conduct and constitute the basis for a shared and regular contact during treatment (Boyer & language, motivation, and contingencies that guide practi- Thompson, 2013; King et al., 2009). This approach has tioners in their interdisciplinary practices and aid in shared substantial benefits for all TD team members. ethical decision making and conflict resolution (Cox, 2012). Professionals who release to the designated provider learn more about their own discipline and clinical skills by Educational Framework for Building Interprofessional assigning rules to their contingency-shaped clinical reper- Practice toires in order to provide support. The designated provider experiences considerable professional development by Although the notion of greatly enhanced collaboration among learning about other professions and expanding their clin- members of a treatment team may seem laudable and strong ical skills. evidence exists to show the efficacy of that approach 3. As central TD features such as arena assessment and role (Berwick, 2019; Berwick et al., 2008; Bodenheimer & release require regular, intensive communication among Sinsky, 2014), as we have discussed, training in this area is Behav Analysis Practice (2021) 14:1238–1248 1241 an ongoing challenge for all of the health disciplines, includ- compassion (Taylor et al., 2018), shared ethical principles ing behavior analysis. The IPEC provides a competency and values (Cardon, 2017; Gerenser & Koenig, 2019; framework for moving toward interprofessionalism (IPEC, Koenig & Gerenser, 2006), and professional humility as dem- 2016; IPEC Expert Panel, 2011), which we will discuss re- onstrated through cultural sensitivity and responsiveness garding its practical adoption as part of a behavior analyst’s (Brodhead, 2015). professional development. Although recent literature shows a growing interest in ad- The IPEC Framework consists of four interprofessional core dressing collaboration and interprofessionalism, this remains a competency domains (hereafter referred to as “domain”) that primarily theoretical enterprise. Instead of rejecting profes- are already well aligned with the principles adopted by behav- sions with a preference for mentalistic constructs, it may ben- ior analysis licensing bodies (i.e., client- and family-centered, efit behavior analysts to operationalize these terms to keep a community- and process-oriented, relationship-based, develop- seat at the table with other disciplines. Behavior analysts are mentally appropriate recommendations that are sensitive to uniquely equipped to operationalize constructs as measurable practice differences and outcome driven; Spencer et al., behaviors. Operationalizing constructs is a useful starting 2021). The IPEC’s domains emphasize “essential behavioral place for shared understanding and empirical inquiry. combinations of knowledge, skills, attitudes, and values that Although an attempt is made to operationalize constructs as- make up a collaborative, practice-ready [environment]” (IPEC sociated with relationship building and effective collabora- Expert Panel, 2011, p. 12; see also IPEC, 2016). tion, it is important to note that dyadic communication in- The four core competency domains include cludes bidirectionality between the speaker and listener and role reversals, that functional descriptions are context depen- 1. Values and Ethics (VE): Work with individuals of other dent, and that preliminary operational descriptions are bound professions to maintain a climate of mutual respect and by the parameters included in the description. The following is shared values. an attempt to bring relevance of the IPEC Framework’s Core 2. Roles and Responsibilities (RR): Share acknowledgment competency domains to the practice of applied behavior of team members’ roles and abilities. analysis. 3. Interprofessional Communication (CC): Communicate in a responsive and responsible manner that supports a team approach to treatment. Values and Ethics (VE) 4. Teams and Teamwork (TT): Apply relationship- and team-building values and principles (IPEC, 2016, p. 10). Work with individuals in other professions to maintain a cli- mate of mutual respect and shared values. The VE domain Each of these domains includes a number of may be relevant to the notion and construct of “culture” that subcompetencies. These subcompetencies provide specific embodies a shared understanding of interprofessional educa- guidance on the specific skill repertoires and competencies tion and collaborative principles. that promote effective collaboration, enhance team-based The VE domain includes 10 subcompetencies that address practices, and strengthen partnerships between professionals the need for practitioners to develop a culture that supports and families. The IPEC Framework domains are consistent IPCP/IPPs by with the mission of the field of applied behavior analysis for large-scale dissemination of the science and efforts to achieve & including the client at the center; mainstream relevance and acceptance (e.g., Friman, 2010; & adopting a shared understanding of values; 2014). & holding high standards of ethical conduct and quality of care; & behaving with honesty, dignity, and integrity; IPEC’s Core Collaborative Competencies & being respectful of others who differ in race, ethnicity, or Through a Behavior-Analytic Lens culture; & respecting differences and valuing the expertise of other Although behavior analysts share an interest with other pro- health professionals; fessionals in improved outcomes for their learners, they may & embracing cultural diversity and individual differences; experience barriers to effective collaboration. It is essential for & working in cooperation by acknowledging differences in behavior analysts to build the necessary collaborative skill opinions while jointly finding common ground and shared repertoires and demonstrate both effective interpersonal skills goals; and professional humility (Brodhead, 2015). Several common & managing ethical dilemmas by reaching consensus and constructs associated with collaboration include effective establishing common grounds and shared goals; and communication, interpersonal skills such as empathy and & maintaining competence within your scope of practice. 1242 Behav Analysis Practice (2021) 14:1238–1248 The VE domain is aligned with the foundational principles skill competency and their own. The behavior analyst in the BACB’s new ethics code (BACB, 2020). The VE then states the following contribution to the treatment subcompetencies may be achieved by engaging in culturally goals: “I may be able to help decrease negative mealtime aware practices, cultural humility, and reciprocity while build- behaviors [by applying behavioral principles such as dif- ing a culture that embraces and reinforces interprofessional ferential reinforcement and extinction], assist with gener- collaboration among professionals from different disciplines. alization by teaching parents [by implementing behavior- Culture may reflect a collection of common verbal and al skills training], increase tolerance of novel textures [by overt behaviors that are learned and maintained by a set of using stimulus fading and counterconditioning], and cre- similar social and environmental contingencies (i.e., learning ate a way for us to monitor progress over time [using history), and are occasioned (or not) by actions and objects operational definitions and data collection].” (i.e., stimuli) that define a given setting or context. (Sugai The behavior analyst then seeks to understand how the et al., 2012, p. 204) speech-language pathologist’s role and skill expertise Additional constructs that play a critical role in building may integrate with their own to further the treatment plan. collaborative relationships but need clear operational defini- The practitioner may start this discussion by asking clar- tions include the following: ifying questions. Questions need to be delivered authen- tically while maintaining psychological flexibility to en- 1. Cultural sensitivity and responsiveness: One is aware of tertain adaptations and modifications to the selection of the contextual conditions within which each person/ goals and intervention. Instead of saying, “Let me show professional operates, and makes appropriate adaptations you what you can do” or “My intervention plan works to establish reinforcing conditions that may foster behav- best,” consider alternatives such as “I am interested in iors in support of positive and effective relationships learning about what you find in your assessment”; “I am (Neely et al., 2019). interested in observing how you address this feeding is- 2. Cultural competence: This is achieved by mastering cul- sue, and I would love to share some strategies I find help- tural competency skills in your educational and clinical ful [such as prompt and prompt-fading procedures and training (Brodhead & Higbee, 2012; Fong & Tanaka, treatment fidelity]”; “Is there anything you recommend I 2013). It would be foolish to assume that one can achieve do or avoid when I implement my strategy [such as ex- mastery in cultural competence given that the words, emplars and nonexemplars]?”; and “What is the best way knowledge, and training one receives do not necessarily to reach you to discuss our plan and share data [regarding translate into a complete understanding of the cultural data decision analysis and progress monitoring]?” norms and contingencies within which people of that 4. Cultural reciprocity: This represents an openness to embrace culture behave. As such, Kalyanpur and Harry (2012) reciprocal learning opportunities by respectfully engaging in argued that to be culturally competent, one needs to en- dialogue and information sharing (Harry, Rueda & gage in cultural humility and cultural reciprocity. Kalyanpur, 1999; Kalyanpur & Harry, 2012). Cultural rec- 3. Cultural humility: One acknowledges their own limita- iprocity may be considered as cultural humility in action. tions and seeks to increase awareness, understanding, According to Kalyanpur and Harry (2012), Harry et al. and respect of others’ cultures to overcome these limita- (1999), and Spencer (2020) cultural reciprocity is achieved tions (Mosher et al., 2017). It is important to note that by engaging in four steps: cultural humility is a challenging construct to demonstrate as “our behaviors, biases, assumptions, the ways in which a. Self-reflecting by being aware of influences of person- we perceive the world, and the decisions we make are all al biases, assumptions, and discipline-specific profes- conditioned and influenced by our learning histories and sional culture Addressed in the IPEC domainS VE our experiences” (Slim & Celiberti, 2021, p. 2). Cultural within the construct of “culture”; humility requires one to exhibit self-awareness regarding b. Listening, inviting, respecting, and acknowledging their own cultural biases. Specifically, identifying and differences in others’ theoretical and cultural assump- discriminating the presence of one’s implicit biases re- tions, beliefs, definitions, and interpretations quire one to be aware of the influence that these biases (Addressed in the IPEC domains RR and CC within may have on the listener’s responses that may affect the the constructs of “competence and communication”; quality of the reciprocal conversations and speaker– c. Validating and engaging in reciprocal conversations listener relationship. For example, a behavior analyst is to explain and understand each other’s theoretical and collaborating with a speech-language pathologist to im- cultural assumptions and beliefs and eliminate possi- plement a feeding program for a child. The behavior an- ble incorrect assumptions or misunderstandings alyst first tacts their private thoughts regarding assump- (Addressed in the IPEC domains CC within the con- tions they may have of the speech-language pathologist’s struct “communication”; and Behav Analysis Practice (2021) 14:1238–1248 1243 d. Collaborating and compromising, reaching consen- It is important to recognize that “knowledge of universally sus, and establishing common grounds and shared applicable principles does not translate to an unconstrained goals (Addressed in the IPEC domains TT within scope of practice or an unlimited scope of competence” the construct of “collaboration”. (Spencer et al., 2021, p. 2). Given that scope of practice and scope of competence are constructs referred to across health and education professions, a shared understanding of what Roles and Responsibilities (RR) they refer to is warranted. Brodhead et al. (2018) referred to scope of practice as “the range of activities in which members Share acknowledgment of team members’ roles and abilities. of a profession are authorized to engage, by virtue of holding a The RR domain may be relevant to the notion and construct of credential or license (p. 426).” In other words, scope of prac- “competence,” which embodies shared respectful recognition, tice mainly consists of the activities, procedures, and process- valued contribution, and integration of discipline-specific es that a licensed or certified professional is authorized to skills and expertise within interprofessional education and engage in within the boundaries of professional practice as collaborative practices. defined by law, regulation, and educational attainment. The RR domain includes 10 subcompetencies that address According to Brodhead et al. (2018), scope of competence the need for practitioners to ensure their competence and be- is referred to as “activities that the individual practitioner can having with integrity in support of IPCP/IPPs by perform at a certain criterion level (p. 424).” In other words, a professional practicing within their scope of competence is & communicating to team members their roles and respon- performing their activities and procedures at a level that meets sibilities, the skilled expertise they can offer, and the ways a specified criterion and standard of excellence. they can contribute to collaborative practice; & engaging IN cultural humility and in self-reflection by Interprofessional Communication (CC) recognizing one’s own limitations in skill, knowledge, and abilities; Communicate in a responsive and responsible manner that sup- & understanding and explaining other team members’ roles ports a team approach to treatment. The CC domain encom- and responsibilities; passes constructs such as communication, perspective taking, & providing ongoing clarification of roles and responsibili- empathy, and compassion, which involve expressing oneself in ties for each component of the treatment plan; a respectful and clear way while also demonstrating respect for & inviting and engaging professionals whose competence the ideas and communication needs of the team, all in support complements one’s own skills; of a larger goal of effective interprofessional teamwork. & integrating the skill expertise and competence of team The CC domain includes eight subcompetencies that ad- members to ensure safe, timely, efficient, effective, and dress the need for behavior analysts to practice professional equitable treatment; communication modalities—oral, written, and gestural—in a & establishing synergistic and interdependent relationships fashion that advances teamwork and interprofessional prac- between team members; tice. The following subcompetencies are highlighted: & incorporating the unique and complementary skills of oth- er team members in one’s treatment; & selecting effective tools and technology; & engaging in continuous professional development; and & replacing discipline-specific jargon with language that is & describing collaboration and integration across profes- understood across the team; sional disciplines. & clearly expressing knowledge and thoughts and listening actively and empathically; The RR domain is aligned with the foundational principles & encouraging other ideas and thoughts and participating in in the BACB’s new ethics code (BACB, 2021). The TT genuine and honest conversations that strengthen shared subcompetencies may be achieved by behaving with cultural values and maintain mutual respect; humility and dignity; by ensuring your own competence while & behaving compassionately and communicating with con- recognizing your limitations in skill, knowledge, and abilities; sideration in ways that meet the needs of colleagues, the and by seeking to increase your understanding of other team team, and clients; members’ roles and responsibilities to benefit others & giving and soliciting feedback in a sensitive, instructive, (LaFrance et al., 2019). Moreover, seeking to understand team and respectful manner; asking about preferred ways to members’ discipline-specific theoretical and cultural assump- deliver feedback; and tailoring delivery to meet those tions, opinions, and values will strengthen the collaborative preferences; relationship by creating a shared understanding of the value & recognizing the value and impact of one’s own and others’ that each team member’s competence brings. professional background and contributions to the team; and 1244 Behav Analysis Practice (2021) 14:1238–1248 & engaging in communication behaviors that foster conflict Empathy resolution (e.g., establish agreements and resolve dis- agreements), including oral, written, gestural, and body Empathy is commonly described using metaphorical tact ex- posturing. tensions such as “walking in another’s shoes” and involves engaging in perspective taking. According to Taylor et al. The CC domain is aligned with the foundational principles (2018), empathy involves a cognitive component (i.e., covert in the BACB’s new ethics code (BACB, 2021). Competence verbal behavior), which consists of perceiving and tacting in the CC domain may be achieved by tactfully and respect- others’ desires or emotional responses, and an affective re- fully communicating one’s own expertise and contributions in sponse (i.e., overt verbal behavior). Typically, that response clear and easily accessible terms, displaying appropriate em- consists of reflecting on one’s own experiences that may elicit pathy and compassion, and demonstrating responsiveness to a similar emotional responses. For example, a parent explaining diversity of cultures and ideas. This is accomplished by re- their concern over their child’s self-injurious behaviors may spectfully understanding others’ perspectives and resolving squeeze their eyebrows together, tighten their facial muscles, conflicts by reaching a shared consensus that places clients’ and increase the pitch of their voice while decreasing volume. best interests first. Signal detection occurs when this compound visual-auditory stimulus evokes the clinician’s statement “I understand that this is very difficult to talk about.” The clinician’s statement Communication may be a member of a functional response class maintained by negative reinforcement (i.e., the attenuation or removal of Extensive work has already been accomplished in the opera- others’ collateral behaviors associated with suffering) or pos- tional analysis of communication beginning with B. F. itive reinforcement (i.e., a socially mediated response by the Skinner’s (1957, 2020) Verbal Behavior. His work provided a parent such as “Thank you for understanding”). method to analyze socially mediated behaviors by classifying them into specific environment–behavior relationships called verbal operants. These functional units of behavior provide an Compassion alternative to a structuralist account of communication and have been the foundation for an important area of applied research Compassion involves empathy plus action aimed at mitigating and practice to improve language habilitation and rehabilitation. a person’s suffering (Diller & Lattal, 2008; LeBlanc et al., 2020). Lown (2014) defined compassion as “the recognition and validation of the needs, concerns and distress of others, Perspective Taking coupled with actions to ameliorate them” (p. 199). Although they are not stated explicitly, the definition alludes to a few Many of the most critical components of effective interprofes- important environment–behavior relationships that, if ade- sional collaboration—empathy, compassion, and quately defined, could become the target of a behavior- collaboration—require perspective taking (Catagnus & change program. Compassion may be more precisely under- Rock, 2020); however, the concept of perspective taking is, stood in physical terms that minimize subjectivity and can be itself, very complex at a behavioral level. Specifically, to en- broken into public and private behaviors. Specifically, the gage in effective perspective taking involves the following signal detection of others’ suffering is under the complex steps: the listener (a) tacting their own covert feelings, stimulus control of public verbal and nonverbal behaviors. thoughts, and assumptions; (b) attending to the speaker’s au- Compassion may be understood by revisiting the previous ditory and visual responses; (c) making inferences about the example and providing an additional action-oriented state- speaker’s thoughts and feelings to interpret their behavior; (d) ment to the clinician’s empathic response. For example, “I attempting to understand the speaker’s point of view in a sit- understand that this is very difficult to talk about” becomes a uation by trying to reflect back to a similar emotional response compassionate statement with the addition “We will work elicited by a personal experience; (e) predicting the behavioral together to teach him how to use his voice to get what he response of the speaker; and (f) finally checking for accuracy wants and needs.” (Catagnus & Rock, 2020; Gould et al., 2011; Taylor et al., 2018). In other words, perspective taking involves the process of prediction and control of the speaker–listener responses. Teams and Teamwork (TT) Perspective taking is necessary when communicating and col- laborating with others, particularly when others come from Apply relationship- and team-building values and principles. varied professional backgrounds. For example, to resolve con- The TT domain may be relevant to the notion of evidence- flict professionally and come to a consensus or to work toward based practice and the construct of “collaboration,” which shared goals requires the skill of perspective taking. embodies shared values, goals, and decision-making Behav Analysis Practice (2021) 14:1238–1248 1245 processes based on team norms and principles including the assumes both individual and shared accountability for the client’s values, preferences, and circumstances. decision-making process. Acquiring the TT competency is con- The TT domain includes 11 subcompetencies that seek tingent on successful performance as an individual practitioner involvement from all team members and by developing shared and as a member of a team. understanding of ethical practice guidelines. The following competencies are highlighted: Collaboration & describing the process and systems that promote team The term “collaboration” is commonly used in clinical prac- development; tice, research, organizations, and health professional educa- & developing and implementing practices based on a shared tion. Collaboration is a process whereby two or more people, understanding of ethical practice guidelines; entities, or organizations work together to complete a task, & engaging in shared problem solving; achieve a shared goal, or engage in shared decision-making & integrating knowledge and experience with client values processes to solve complex issues (Green & Johnson, 2015). and preferences; Engaging in perspective taking will enhance collaboration and & engaging in leadership practices by seeking the involve- cooperation, as it promotes self-reflection, active listening, ment of all team members; understanding, and validation of colleagues’ and other team & engaging in constructive conflict resolution by respectful- members’ points of view. ly reaching consensus; A conceptual definition of the term “collaboration” includes a & engaging in shared accountability for outcomes with team set of behaviors that are observed as an extension of communi- members; cation acts and involves the dynamic interaction of complex & reflecting and providing feedback on individual and team intraverbal behaviors between two or more individuals. performance for improvement; Members of a collaborative relationship whose behaviors are & using process performance feedback and improvement to reinforced by the culture and verbal community may be referred increase effectiveness; to as a “team.” The quality of interactions and broader relation- & using available evidence and data-driven processes to in- ships is strengthened by the reinforcing effect of the ethical prin- form effective teamwork and practices; and ciples, values, and contextual and motivational variables of the & performing ethically, competently, and effectively on individual members. Ethical principles, values, and respect are teams and within different team roles. constructs derived from what the culture and verbal community accept or reject as their members’ behavioral responses (e.g., Ethical guidelines have been cited as an important starting reinforced or punished), the contingencies agreed upon by mem- place for the creation of standards and expectations to guide bers of that community, and the conditioned reinforcement that is professional behavior in practice (Cox, 2012; IPEC, 2016). established and maintained within that verbal community. Evidence-based practice is a framework and ethical principle Effective communication and collaboration are observed adopted by health, social science, and medical professions that when the strength and quality of team members’ communica- practitioners must abide by to ensure optimal and safe client tion are mediated by team membership reinforcement. health outcomes. A shared understanding of evidence-based However, it is critical to understand the complex controlling practice is central to joint, effective, cohesive, and competent variables (i.e., audience, motivational variables, and contextu- teamwork practices and aligns with principles of applied behav- al variables), as these will allow for the prediction and control ior analysis. Evidence-based practice is a collaborative decision- of the behavioral responses of each member and the “team” as making approach where practitioners integrate the best available a unit. By effectively controlling for these factors, one can external scientific evidence (empirical evidence); internal evi- increase the likelihood that the collaborative-communication dence (informed by data and evaluation of client performance); behavioral response will be effective. However, the analysis clinical expertise and judgment; and client perspectives, values, of all the controlling variables may be expansive given the and preferences (Higginbotham & Satchidanand, 2019; Slocum complexity of each individual’s learning history. et al., 2014). Evidence-based practice involves processes that are Consequently, the verbal behavior of a specific community fluid and dynamic, based on evidence that evolves with new is not always based on the simple and pure interactions and scientific discoveries and client progress. The evidence-based learning histories of both speakers and listeners (i.e., profes- practice framework is at the center of the TT domain of collab- sionals from different disciplines). The contingencies within orative practices and is aligned with the foundational principles which people interact and communicate are determined by the in the BACB’s new ethics code (BACB, 2020). The BACB verbal community or culture that they belong to—in this case, code requires practitioners to apply evidence-based practice with theoretical, philosophical assumptions and conceptual frame- cultural humility and display sensitivity and responsiveness to- works that are implicitly or explicitly expressed in the code of ward colleagues and the client. Evidence-based practice ethics of each professional discipline (Cox, 2019). 1246 Behav Analysis Practice (2021) 14:1238–1248 Collaborative Practices practitioners to behave with professionalism by adopting evidence-based practices, seeking continuing professional de- Effective collaborative practices require interdependence and velopment activities, and building an interprofessional collab- the application of each team member’s knowledge, skills, and orative culture. Beyond the prospect for professional and per- contributions to execute a cohesive and integrated plan of care sonal development, culturally responsive IPCP/IPPs may op- (Pawlenko, 2005). The collaborative relationship embodies timize client outcomes and enhance clinical care through the principle of practitioner equity and is neither hierarchical team-based decision-making processes. nor competitive. There are already established benefits of IPCP/IPPs for clients’ overall health outcomes, as demonstrated by the Cooperation IOM (IOM Committee on Quality of Health Care in America, 2001) and the health sciences and medical fields. Cooperation and collaboration are often used interchangeably Specifically, preventing unnecessary, redundant, inconsistent, in the workplace. Although not exclusive of one another, they or conflicting treatments can reduce the cost of care and opti- do differ in some critical ways. The major differentiating fac- mize the quality of service delivery. Moreover, IPCP/IPP has tor is that in collaboration, practitioners work together toward been shown to promote professional development and foster a shared goal, engaging in joint decision-making processes positive personal and collegial relationships. Limited, or lack- and sharing accountability for outcomes. By contrast, cooper- ing, behavior-analytic empirical validation of the effects ation involves working with other people to achieve one’s IPCP/IPP have on client outcomes should not lead behavior own goals or to help others achieve their goals (Oxford analysts to dismiss the documented positive benefits observed Learner’s Dictionary, English Language Desk, n.d.). Of for personal and professional development, staff satisfaction, course, team members often cooperate in support of one indi- quality of service delivery, and overall client health outcomes vidual’s specific responsibility; however, this cooperation is (IHI, 2008; IOM Committee on Quality of Health Care in in the context of the larger team’s goal. America, 2001). Although scientific, empirical investigations must be un- dertaken, behaving with interprofessionalism is well aligned Discussion with the foundational principles in the BACB’s new ethics code (BACB, 2020) and can enhance the public image of This conceptual article is a first attempt at operationalizing and behavior analysis as a discipline that values interprofessional highlighting the potential relevance of the IPEC Framework collaborative and culturally responsive practices. This will as a viable framework that behavior analysts may use to in- ultimately promote the mainstream relevance of behavior form themselves regarding competency benchmarks that are analysis and increase opportunities for impacting and benefit- indicators of cultural humility, cultural awareness, and respon- ing society in meaningful, scalable, and long-lasting ways. sive interprofessional collaboration. The literature points to the general benefits of interprofessionalism, such as more effective and positive client Author Note We wish to thank our colleagues for inspiring, mentoring, and encouraging us to share our vision and data; our family and friends outcomes and improved personal and professional growth. for believing in our mission and for their unconditional support and pa- Research on the application of interprofessional, relationship- tience throughout this process; and the New Jersey Speech and Hearing building skills and collaborative competencies, although emerg- Association for championing interprofessional education and collabora- ing, offers opportunities for empirical validation to identify the tion and supporting the initiative for developing an Interprofessional Autism Conference that was the inspiration for moving forward on this variables that influence collaboration. Once identified, these var- interprofessional education and collaboration project. iables could support the development of organizational systems to build cultural awareness and responsiveness and collaborative Authors’ Contributions The idea for the current work, completion of the competencies in the field of applied behavior analysis. literature review, comparative descriptive analysis, writing of the manu- Although skills associated with building relationships and script, and any revisions are and will be the work of Lina Slim and Lilith Reuter-Yuill, authors. strengthening collaboration require further empirical valida- tion, it is the responsibility of professional behavior analysts Availability of Data and Materials The article includes the collection of to display responsiveness to the changing environmental fac- original data. tors and educational landscape of the helping professions. This may be achieved through interprofessionalism. Declarations To date, research has not systematically evaluated the rel- ative value of different interprofessional collaborative systems Conflicts of Interest The authors have no conflicts of interest or com- in education or practice. Until researchers conduct these eval- peting interests to disclose with regard to the current article. uations, behavior analysts have the responsibility as Behav Analysis Practice (2021) 14:1238–1248 1247 References Foley, G. (1990). Portrait of an arena evaluation: Assessment in the trans- disciplinary approach. In E. Gibbs & D. Teti (Eds.), Interdisciplinary assessment of infants: A guide for early interven- Behavior Analyst Certification Board. (2020). Ethics code for behavior tion professionals (pp. 1-68). Paul H. Brookes. analysts. Littleton, CO: Author https://www.bacb.com/wp-content/ Fong, E. H., & Tanaka, S. (2013). 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