Compassionate care in behavior analytic treatment: Can outcomes be enhanced by attending to relationships with caregivers?
Reviewed by Maithri Sivaraman, MSc, BCBA
Compassion comes from the Latin roots com meaning “together with,” and pati meaning “to bear or suffer.” Compassion is built on the capacity to empathize, but it takes empathy one step further because the individual desires to alleviate the suffering of another person. Although this is not a new subject within the healthcare services, there is now increasing research and discussion on the role of compassion among professionals, especially those involved in counselling and psychotherapy (Sinclair, Kondejewski, Raffin-Bouchal, King-Shier, & Singh, 2017; Singh et al., 2018). Behavior analysts across the world work in a gamut of roles in schools, companies or businesses, and in multi-disciplinary teams with other professionals, families, or employees. Yet all of these roles have at least one thing in common: the likelihood of a large amount of engagement with other people. Interestingly, as rigorous and intense as academic training in behavior analysis is, it does not always incorporate skills in relationship building (Pastrana et al., 2016). In a significant and timely article published in Behavior Analysis in Practice, Taylor, LeBlanc and Nosik (2018) discuss the important therapeutic relationship skills that should inform the repertoire of a behavior analyst and describe strategies to cultivate these skills.
The authors posit that behavior analysts’ technical skills will ultimately determine client outcomes, but improvements in interpersonal skills and relationship building strategies may enhance the service providers’ overall professional competencies. The authors state that the majority of ethics complaints filed against a behavior analyst are by consumers or families that they serve, and not by a colleague or co-worker. Therefore, a failure to build effective relationships with clients may indirectly affect treatment outcomes, and adherence to program implementation.
The distinction between sympathy, empathy and compassion
Taylor et al. (2018) described sympathy as feeling sorry, or sad for another person’s suffering, but not necessarily experiencing a shared pain. They distinguish sympathy from empathy by saying that the latter involves “walking in another’s shoes,” in that empathy requires perception and understanding of the other person’s perspective. They say that compassion differs from empathy due to the individual’s attempt to alleviate the pain/suffering that another person is undergoing. According to Taylor and colleagues, in behavior analytic terms, the use of compassion would entail identifying the discriminative stimuli of a likely private event that the client is experiencing and responding in accordance with a similar event that occurred to oneself in the past.
The researchers conducted a survey to measure clients’ (parents of children with autism) perception of three different clinical skills and challenges in the behavior analytic services they receive: the therapist’s ability to listen and collaborate with families, the therapist’s compassion and empathy, and events that contribute to problems in the therapeutic relationship. They recruited 95 respondents in all, and recorded survey responses on a 5-point scale, from strongly disagree to strongly agree. Behavior analysts performed well on certain aspects of the three variables. They scored high on items such as listens to concerns during the first meeting, protects confidentiality, acknowledges and celebrates my child’s accomplishments. However, several core relationship-building skills (e.g., checking if the parent was happy with the way the child was doing, asking the parent how they were feeling, reassuring the parent that things would get better, acknowledging the behavior analyst’s own mistakes) were identified to be deficient. Although we must interpret these results cautiously due to the small sample size, and nature of data collection, training programs for behavior analysts targeting these skills might be beneficial in enhancing their overall effectiveness.
Overcoming barriers to compassionate care
As is consistent with all behavior analytic programs, we design an intervention for a deficient behavior only after we conduct an inquiry into the environmental variables surrounding the behavior and identify suitable targets. Taylor and colleagues (2018) identified five major factors that could serve as barriers to compassionate care. These include poor relationship building skills, lack of formal training in relationship-building skills for behavior analysts, minimal funding in service delivery that does not allow for time to build relationships with the client’s family, or a lack of experience with the range of emotions that are experienced by families during the course of intervention, and interpersonal factors such as stress and burn-out for the behavior analyst. They also noted the specific role of self-compassion in developing compassion towards others. Being overly critical of one’s own self, and negative self-assessment preclude the extension of compassion towards others.
Next, the authors outlined curricula that target compassion and relationship-building skills. Examples of skills that could be taught to behavior analysts include expressing appreciation, making positive comments about the child and the parent, asking open-ended questions, and inquiring about the parent’s feelings and general well-being. The authors also list specific therapist behaviors to monitor and avoid such as interrupting the parent, jumping to solutions too quickly, or providing many negative comments.
As the authors suggest, behavior analysis should begin to articulate the responses that comprise compassionate care, set up practicum sites with a focus on teaching these responses, and design studies that assess the collateral benefits of these responses on treatment outcomes and social validity of interventions. The universality of compassion and empathy in all roles that behavior analysts pursue makes a compelling rationale for our attention and inquiry.
Pastrana, S., Frewing, T., Grow, L., Nosik, M., Turner, M., & Carr, J. (2016). Frequently assigned readings in behavior analysis graduate training programs. Behavior Analysis in Practice, 3, 1–7. doi: 10.1007/s40617-016-0137-9
Sinclair, S., Kondejewski, J., Raffin‐Bouchal, S., King‐Shier, K. M., & Singh, P. (2017). Can self‐compassion promote healthcare provider well‐being and compassionate care to others? Results of a systematic review. Applied Psychology, Health and Well‐Being, 9, 168–206. doi:10.1111/aphw.12086
Singh, P., Raffin‐Bouchal, S., McClement, S., Hack, T. F., Stajduhar, K., Hagen, N. A., & Sinclair, S. (2018). Healthcare providers’ perspectives on perceived barriers and facilitators of compassion: Results from a grounded theory study. Journal of Clinical Nursing, 27, 2083-2097. doi: 10.1111/jocn.14357
Taylor, B. A., LeBlanc, L. A., & Nosik, M. R. (2018). Compassionate care in behavior analytic treatment: Can outcomes be enhanced by attending to relationships with caregivers? Behavior Analysis in Practice. Advance online publication. doi: 10.1007/s40617-018-00289-3
Citation for this article:
Sivaraman, M. (2019). Review of “Compassionate care in behavior analytic treatment: Can outcomes be enhanced by attending to relationships with caregivers?” Science in Autism Treatment, 16(1).