Increasing Cultural Understanding and Diversity in Applied Behavior Analysis

Elizabeth Hughes Fong Saint Joseph’s University

Seana Ficklin Multicultural Alliance of Behavior Analysts,

Swarthmore, Pennsylvania

Helen Y. Lee Boston University

In recent years, the demands for behavior analysis to serve consumers with diverse cultural backgrounds have significantly increased. The field is in great need of culturally competent behavior analysts who can integrate appropriate cultural considerations to their programs. The field of behavior analysis can address this growing need by fostering cultural compe- tency in professional training through increasing relevant training opportunities and the development of culture- and diversity-relevant educational curricula and materials, and by supporting efforts to increase the number of ethnically and racially diverse behavior- analytic workforces in academic and professional settings. Together, we can promote cultural awareness and cultural competencies in professional behavior-analytic training. However, there are challenges for fostering culturally diverse professionals, especially during the academic training phase, which include language barriers, negative perceptions about cultures that are different from one’s own, microaggressions in work and academic settings, lack of mentoring opportunities, adverse campus climates, and tokenism. Some potential ways to address such challenges include the development of culture- and diversity- related curricula, mentoring opportunities, and greater support for minority and culturally diverse students and faculty. The purpose of this commentary was to increase awareness about the importance of cultural understanding and competency, as well as a diverse workforce in the field of behavior analysis, a necessary step to better serve those consumers from multicultural backgrounds.

Keywords: behavior analysis, diversity, multiculturalism

Today’s behavior analysts serve consumers from increasingly diverse ethnic, racial, and so- cioeconomic backgrounds, and this trend will

likely continue as the field expands. To better serve consumers from different cultures, includ- ing historically marginalized ethnic and racial populations in the United States, the field of applied behavior analysis (ABA) needs to rec- ognize the cultural diversity of consumers and critically examine the role of culture in effective treatment design, practice, and delivery. Cul- tural competency is no longer an option but a necessity for serving an increasingly multicul- tural background of consumers. Behavior ana- lysts need to be aware of how their own cultural values and beliefs or the lack of understanding of their consumers’ cultures can negatively im- pact treatment and service delivery. To this end, we believe good starting points are the promo- tion of cultural understanding and skills in be- havior-analytic education and training and of supporting diversity in the ABA workforce. To-

Editor’s Note. Alan Poling served as the action editor for this article.—AP

This article was published Online First February 16, 2017. Elizabeth Hughes Fong, Department of Health Services,

St. Joseph’s University; Seana Ficklin, Multicultural Alli- ance of Behavior Analysts, Swarthmore, Pennsylvania; Helen Y. Lee, Department of Psychological and Brain Sci- ences, Boston University.

Helen Y. Lee is now at the Department of Comparative Human Development, University of Chicago.

Correspondence concerning this article should be ad- dressed to Elizabeth Hughes Fong, Department of Health Services, St. Joseph’s University, 5600 City Avenue, Post Hall Room 123, Philadelphia, PA 19131-1395. E-mail: [email protected]

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Behavior Analysis: Research and Practice © 2017 American Psychological Association 2017, Vol. 17, No. 2, 103–113 2372-9414/17/$12.00 http://dx.doi.org/10.1037/bar0000076

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gether, we can enhance the quality of ABA services to consumers from diverse ethnic and racial minority groups by providing culturally more effective and satisfying programs.

In the United States, racial and ethnic demo- graphics have been undergoing significant changes, with a rapid and considerable growth of non-White populations during the last decade (Humes, Jones, & Ramirez, 2011; U.S. Census Bureau, 2013). For example, the non-White Hispanic population grew by 43% between 2000 and 2010, and non-White Hispanics are projected to constitute one third of the United States population by the end of 2060 (U.S. Census Bureau, 2013). Meanwhile, public health services in the United States are signifi- cantly ill-equipped to meet the needs of rapidly growing multicultural populations over the past few decades, and significant disparities already exist in health-care quality and access (Brady, Ho, Kelley, & Clancy, 2007; DHHS, 2014). This unfortunate trend reflects a long history of health-care inequality in the United States and an ongoing struggle to remediate the disparity.

Elimination of the health-care disparity be- tween the majority and ethnic and racial minor- ity populations became a major part of the na- tional health agenda particularly after the 1960s, as a result of a number of historical and ongoing social and cultural events and changes took place, for example, the civil rights movement, mental health reforms, and growing immigra- tion (Derose, & Escarce, & Lurie, 2007; Hoff- man, 2003; Smith, 1998). Over the years, vari- ous stakeholders, including federal agencies and public and private organizations, have worked to address this inequality, and numerous schol- ars have examined its causes, potential solu- tions, and their outcomes (Fiscella, Franks, Gold, & Clancy, 2000; Smedley, Stith, & Nel- son, 2002; van Ryn & Burke, 2000). A large body of literature has indicated that health- service disparity is the result of complex mul- tidimensional layers of barriers and requires ongoing and wide-ranging corrections (Baker et al., 2010; Flores, Abreu, Olivar, & Kastner, 1998). The barriers include consumers’ lack of proficiency in the English language (illiteracy), their negative perceptions of health establish- ments, an insufficient number of health profes- sionals with diverse cultural backgrounds, and unsupportive social and academic systems that fail to foster the potential of students of color to

become competent professionals. Presently, the extent to which ABA professionals provide ser- vice to culturally diverse and minority popula- tions is unclear, as are the percentages of pro- fessionals with different cultural backgrounds (e.g., ethnic and racial backgrounds) and the types of challenges professionals face when working with individuals from cultural popula- tions that are different from theirs.

The ABA field currently lacks culturally rel- evant behavior-analytic knowledge and profes- sional training materials. Yet, according to a recent large-scale survey study by Fong, Jar- muz-Smith, Dogan, Serna, and Woolery (2015), behavior analysts are increasingly interested in obtaining such knowledge. The study found that the more experienced behavior analysts are, the greater the importance they assign to including cultural competency in professional training for working with consumers from different cul- tures. The study concluded that there is a grow- ing and immediate need for developing and testing professional development programs aimed at increasing cultural competency.

As the field of behavior analysis currently goes through an important phase in its growth, it is necessary to recognize the cultural diversity of its consumers and the impact of this diversity on research and the theory, practice, and delivery of ABA services. Cultural sensitivity can contribute to creating better service for consumers from dif- ferent cultural backgrounds and greater service equality for minority populations. In particular, we believe that increasing diversity in the behavior- analytic workforce, together with developing cul- ture-relevant education and training materials, can play a pivotal role in improving the cultural com- petencies of behavior analysts and better serving diverse populations. In this commentary, we ex- amine the important role of culture in health ser- vices and the importance of fostering racially and ethnically diverse professionals. Then we discuss social barriers that need to be addressed to achieve this cultural diversity, as well as potential solu- tions to these challenges. Finally, we present our conclusion and future research directions.

Importance of Cultural Understanding and Diversity

Culture plays a critical role in how individu- als develop and function in a society; it guides and shapes their values, beliefs, and behavior

104 FONG, FICKLIN, AND LEE

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throughout their lives (e.g., Shweder & LeVine, 1984). According to Skinner (1971), culture is a collection of the contingencies of reinforcement into which individuals are born and to which they are exposed throughout their lives. The contingencies are part of both the social and the physical environment and may not be readily observable, especially in the case of social con- tingencies in which the reinforcers are values and ideas that generate the behavior. Different cultures offer unique contingency environments that shape and influence individuals’ behavior (Glenn, 2004; Skinner, 1971). In particular, cul- ture influences the perceptions and behaviors of clinicians as well as consumers, including their expectations regarding appropriate behavior in social situations (Glenn, 2004; Skinner, 1971).

Individuals’ cultural identities and connec- tions to their families and communities are es- pecially relevant in the mental health-service setting. Culture may influence how a condition impacts an individual and may manifest as a syndrome (culture-bound syndrome) and also affects how these are treated (Marsella & Yamada, 2000). Specifically, culture can influ- ence the likelihood of individuals seeking help or treatment, the type of treatment they seek, and the coping styles they use, within a broader ecological context of available support systems and stigmata attached to their conditions (DHHS, 2001).

At the most basic level, cultural competency begins with recognizing one’s cultural identity (Fong, Catagnus, Brodhead, Quigley, & Field, 2016). Cultural identity can be viewed in terms of distinguishable stimulus and response class- es: Being aware of one’s cultural identity allows for an awareness of how one’s values, prefer- ences, characteristics, and circumstances may differ from those of others. This self-awareness can, in turn, help behavior analysts be vigilant regarding unintentional biased perceptions or disregard for others’ cultural beliefs and behav- iors, thus allowing them to develop assessments and interventions that are better suited to the needs of their clients. Findings from psycholog- ical studies have, in fact, shown that clinicians’ competency in cultural knowledge can signifi- cantly improve the quality and effectiveness of health-service delivery to minority populations (e.g., Ngo-Metzger et al., 2006). Moreover, cul- tural sensitivity and understanding can also help clinicians build better relationships with con-

sumers with ethnic and racial minority back- grounds who may have negative perceptions of the establishment due to past unfair social and political treatments.

A report from the Office of the Surgeon Gen- eral (DHHS, 2001) suggested that minority pa- tients were more likely to perceive that differ- ences between their cultural values and beliefs and those of mainstream ethnic majority clini- cians could result in bias and inadequate service on the part of the clinician. That is, when clini- cians hold negative stereotypical images of a minority, this can influence the type and timing of the diagnosis and treatment options they give to consumers. A study comparing the treatment rate of European American and African Amer- ican boys who received a diagnosis of attention- deficit/hyperactivity disorder (ADHD) found that the African American boys were less likely to be recommended for and receive treatment than were their European American counter- parts (Maddox & Wilson, 2003). Clinicians who are not culturally aware are more likely to misunderstand cultural influences in differences in normative behavior can lead to pathologizing behavior (e.g., misperception and misdiagno- sis), and therefore may be more likely to mis- diagnosis minority clients (McIntyre, 1996). In addition, studies have shown that differences in the treatment of ethnic and racial minorities can also result from other factors, such as limita- tions of available health-care options, bias or stereotyping in diagnosing minority consumers, and a lack of culturally competent clinicians (Bailey & Owens, 2005).

However, with proper education and training, professionals of any cultural background can develop the necessary skills to treat and interact with consumers who come from outside their culture. For example, Diller and Moule (2005) suggested that teachers can be educated in cul- tural competency by focusing on developing personal and interpersonal awareness and sen- sitivities, acquiring different bodies of cultural knowledge, and mastering a set of skills for effective communication and teaching. The Na- tional Education Association (2008; NEA) fur- ther developed these ideas and identified four basic cultural competency skill areas for educa- tors: valuing diversity, being culturally self- aware, understanding the dynamics of cultural interactions, and institutionalizing cultural knowledge and adapting to diversity. Specifi-

105CULTURE UNDERSTANDING AND DIVERSITY IN ABA

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cally, professionals need to value diversity and respect different cultural values, traditions, and communicative styles; be aware of ways in which their own cultural beliefs, values, and knowledge shape who they are within their so- cial and cultural community and how they be- have with others; and understand that a number of factors can influence dynamic cultural inter- actions, including historical experiences. Fi- nally, there is a need to institutionalize the prac- tice of integrating the cultural backgrounds of students and knowledge about these into learn- ing environments. The NEA argued that with the development of educators’ cultural attitudes, skills, and knowledge toward valuing diversity, they will be better equipped to serve diverse children. Similarly, by cultivating cultural com- petence in behavioral analysts’ education and training, the field of ABA can better serve di- verse populations.

In addition to focusing on educating ABA professionals in general, another way to strengthen cultural competence in the field is to increase the number of culturally diverse pro- fessionals. Health studies have long established that increasing the number of ethnically and racially diverse health professionals is a critical component for serving their communities more efficiently (e.g., Phillips & Malone, 2014) and closing the gap in health-care disparity (Thomas, 2014). Cultural natives can overcome communicative barriers with non-English- speaking or illiterate consumers and can also more accurately understand culture-related en- vironmental contingencies and contexts, and thus help in assessing and designing socially (culturally) appropriate behavior programs. They can also help in building trust and main- taining rapport with consumers by virtue of being members of a racial or ethnic group, and therefore knowledgeable about its cultural nu- ances in social interactions.

The ABA profession can benefit from cultur- ally knowledgeable analysts in its efforts to effectively reach and work with diverse cultural populations. Culturally diverse professionals can introduce ABA to ethnic and racial com- munities that may not be familiar with the field, and can also share their cultural knowledge with other professionals who may not readily under- stand or may even miss subtle environmental contingencies (Bolling, 2002). A culturally di- verse group of behavioral analysts can serve as

a valuable pool of informers who can share their cultural knowledge and contribute to the devel- opment of cultural concepts relevant to behav- ior-analytic theory, research, and practice in line with the core mission and principles of ABA.

In sum, building cultural competency will contribute to the critical task of enhancing ABA professionals’ ability to work effectively in cross-cultural settings. The best ways to accom- plish the latter involve developing culture- relevant educational and training materials and curricula along with fostering diversity in the behavior-analytic field by having more minority and culturally diverse groups participate and share their cultural knowledge to advance ABA.

Barriers to Increasing Diversity

Although various government and public and private organizations and institutions have de- voted considerable effort to increasing ethnic and racial diversity in the health-care service area, barriers continue to exist. Among various views that have been used to examine the chal- lenges associated with achieving health equal- ity, the critical race theory (CRT) framework provides useful insights for understanding the social and economic factors that underlie sys- tematic resistance to diversity. CRT attempts to understand race, racism, and inequality by ex- amining the power relationship in which the dominant culture’s ideology impacts popula- tions of people who are in the minority with respect to race, gender, and class (Solórzano, 1997, 1998; Solórzano & Delgado Bernal, in press; Solórzano & Yosso, 2000). In this view, the health-service disparity is a result of imbal- anced social and economic power relationships among major and minor ethnic and racial pop- ulations that have manifested as discouraging messages in subtle and overt everyday interac- tions and limited access to resources (Solór- zano, 1997, 1998; Solórzano & Delgado Bernal, in press; Solórzano & Yosso, 2000). CRT offers insights, perspectives, methods, and pedagogies that can guide our efforts to identify, analyze, and transform the structural and cultural aspects of education that maintain dominant and subor- dinate racial positions inside and outside the classroom (Matsuda, Lawrence, Delgado, & Crenshaw, 1993; Tierney, 1993). In what fol- lows, we review some key features identified by CRT to describe the barriers to achieving diver-

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sity that need to be overcome. These include racial microaggressions, inadequate opportuni- ties to receive mentoring, adverse campus racial climates, and tokenism.

Microaggressions

Racial microaggressions are brief, uncon- sciously denigrating messages to people of color in the form of subtle snubs or dismissive looks, gestures, and conversational tones during everyday exchanges (Sue et al., 2007). There are three forms of microaggressions: microin- sults, -assaults, and -invalidations. Microinsults are race-based statements that are rude and de- meaning to a person (Clark, Mercer, Zeigler- Hill, & Dufrene, 2012), such as insensitive statements made to minorities about the “sur- prising” capabilities they possess. Microassaults are more blatant forms of racism meant to insult or hurt the intended victim (Sue et al., 2007), and microinvalidations are statements or actions that invalidate or nullify a person’s feelings, experiences, or beliefs based on his or her race (Clark et al., 2012).

The literature suggests that such microag- gressions are potential sources of stress for stu- dents of color, especially in negative racial cli- mates on campus. These stressors may involve the European American majority’s precon- ceived notion of how minorities make it to college.

According to Sue et al. (2008), African American students and staff have been per- ceived in numerous focus-group studies as less intelligent than ethnic majority individuals, as potential criminals, or even as coming from an inferior culture. Such negative perceptions can have psychological implications and contribute to racial disparities in employment, education, and health care (Sue, 2010). When the micro- aggressions are severe, minority students report emotional distress: they feel overlooked, iso- lated, and rejected, which leads to depression and anxiety—and these can, in turn, impact students’ academic engagement and subsequent outcomes (Fredricks, Blumenfeld, & Paris, 2004). Microaggressions, together with minor- ity individuals’ feelings of alienation and pow- erlessness, can lead to mental exhaustion and significantly interfere with students’ ability to fully engage in academic studies (Yosso, Smith, Ceja, & Solórzano, 2009).

Lack of Opportunities to Receive Mentoring

Inadequate opportunities to receive mentoring constitute another barrier for minority students’ and junior faculty’s success in academic and pro- fessional settings. According to Johnson and Rid- ley (2004), mentoring is an informal, unofficial, mutually agreed upon, and voluntary interaction between two people in which one or more expe- rienced persons share expertise with a less expe- rienced person. The mentoring process involves the mentee observing, questioning, and observing while the mentors demonstrate, explain, and mod- el. Although the literature suggests that mentor- ship has a strong and essential role in facilitating ethnic minority students’ success in completing a degree program, mentoring opportunities remain low, particularly opportunities with another mi- nority member as a mentor (e.g., Gilbert & Ross- man, 1992; Johnson, 2002).

As new faculty members, junior faculty can better decipher an institution’s expectations with respect to retention, tenure, and promotion under the guidance of a mentor (Vasquez et al., 2006). Minority faculty report that lack of sup- port and guidance is a greater problem for them in adjusting to their jobs than for their European American counterparts, especially at predomi- nantly European American institutions (Vasquez et al., 2006).

Adverse Campus Racial Climate

An open, ethnically and racially diverse climate is essential for encouraging minority students to pursue further academic educa- tion. The social climate of professional envi- ronments is reflected in multiple layers of institution-level access to academic re- sources, beyond a cordial and friendly social atmosphere for creative collaborations. A col- legial racial climate that is positive entails greater inclusion of minority students, fac- ulty, and administrators, more diverse aca- demic curricula and programs related to the historical and contemporary experiences of people of color, an active policy and pro- grams to support the recruitment, retention, and graduation of minority students, and a university mission statement that includes the institution’s commitment to pluralism (Yosso et al., 2009). These elements are least likely

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to exist on campuses that have negative racial climates.

Creating and maintaining a genuinely di- verse racial environment has proved to be an ongoing social and political challenge. Some scholars have pointed out that, today, with colorblindness and race-neutral politics being popular notions, it is easier for many univer- sities and institutions to endorse what seems to be a diversity of convenience than to pur- sue genuine diversity or pluralism (Yosso et al., 2009). That is, universities may celebrate diversity with ethnic