April 9, 2024

Feeling Better: A Conversation about Acceptance and Commitment Training with Tom Szabo, Ph.D., BCBA-D, LBA

Tom Szabo (he/they) is a peer-reviewed ACT trainer, Board Certified Behavior Analyst (BCBA), and a behavior analysis professor. He received his masters and doctorate degrees at the University of Nevada, Reno, where he studied under W. Larry Williams and Steven C. Hayes. Over the past fifteen years, Tom has focused his practice on teaching people ways to ignite psychological flexibility in their personal lives. He has developed iterations of ACTr for autistic people, their parents and caregivers, siblings, and staff members. His research focuses on the development of ACTr functional analysis and treatment that addresses issues related to race, gender, class, ethnicity, neurodiversity, disability, language, and dialect. Through the Commit & Act Foundation, Tom has trained therapists in Sierra Leone working with individuals who’ve committed acts of gender-based violence. He has published empirical and conceptual papers, as well as several book chapters and is currently conducting funded research on ways to reduce intrafamilial violence. Additionally, Tom recently authored ACT and Applied Behavior Analysis: A Practical Guide to Ensuring Better Outcomes Using Acceptance and Commitment Training and currently works with individuals and groups in private practice.

I first learned of Acceptance and Commitment Therapy (ACT) in graduate school by way of a 1998 article titled, “Why Behavior Analysts Should Study Emotion: The Example of Anxiety,” written by Drs. Pat Friman, Steven Hayes, and Kelly Wilson. I was immediately intrigued because ABA traditionally focuses more on observable behaviors (overt behaviors) than those that cannot be observed (covert behaviors), including emotions. It is truly an honor to have this discussion with Dr. Szabo, who, as noted above, studied under Dr. Hayes, and is considered an expert in Acceptance and Commitment Training (ACTr), the designation for Acceptance and Commitment Therapy (ACT) implemented outside of psychotherapy settings, such as in ABA (Kelly & Kelly, 2021).

Could you briefly describe Acceptance and Commitment Training (ACTr)?

It’s an approach to helping people get unstuck. It was developed because we all get stuck when we start talking to ourselves in particular ways. I get stuck when I start saying to myself, I can't have this emotion show up. I get stuck when I start saying to myself, This is the way it's supposed to be. I can't let this go. I get stuck when I start saying to myself that I'm this way and they're that way. I get stuck when I say to myself, It's always been this way, or It's never going to change. I get stuck when I start saying to myself, I don't have any purpose. I don't have any meaning. And I get stuck when I say to myself, I'm just going to do what feels good. I don't care what the long-term costs are. I'm just going to do what feels good right now. 

Those are six patterns of self-talk that all of us get trained in when we're young. ACTr is a way of helping people identify their ways of talking to themselves and finding ways to free themselves from their self-limitations. We have no way to get rid of these ways of speaking to ourselves. They're going to continue to be part of our lives because they've been taught to us since we were little. At the same time, we can learn to live in a way that is acknowledging of the thoughts we have. By allowing in emotions that are difficult. Being in the present moment. Holding our thoughts about ourselves a little lightly. Identifying what's important and taking action.

How does ACTr relate to and differ from traditional ABA? 

Traditional ABA has always had a little bit of ACTr inside of it, but it's just a question of emphasis. Traditional ABA has been focused on effective action—on successfully moving towards things that matter, and ACTr is all about that. Traditional ABA has also focused on the measurement of behavior that we can see with our own eyes (overt behavior). ACTr has always been about that, too. Because emotions, thoughts, memories, and even bodily sensations are not observable to others, traditional ABA has not paid much attention to those things. Traditional ABA has never said you don't have thoughts, or that you're not thinking, or that your emotions don't matter. But traditional ABA has said, because we can't measure these things, we're going to leave those to other people to manage. ACTr says—wait a minute—these are important parts of the human experience. And even if they don't cause you to behave a particular way, they're still important. They're important for us to approach and to talk about in some way. So, when we're working with little kids, if we completely avoid talking about emotions, we send them a message that their emotions don't count. ACTr is the perspective that in helping people to behave more effectively in the world, we also owe it to them to attend to their emotional world. That's the principal difference.

A common criticism of ABA is that it can’t support individuals with lower support needs. Taking an ACTr perspective into consideration, how do you respond to statements of this nature?

That's a lovely question. I believe that ACTr is very useful for everyone—professionals, parents, adults, individuals with higher support needs, and those with lower support needs. Once someone is talking, they're talking to themselves. And anyone who engages in self-talk would benefit from opening the doors to that echo chamber and letting other people in to provide alternative ways to engage in self-talk.

The thing that has been the thorn in the side of applied behavior analysis is that it emerged from an effort to identify the basic principles of learning. Initially, so much effort was put into developing strategies helping individuals with higher support needs and not enough effort was placed on developing strategies to help those with lower support needs. ACTr bridges that gap because people with lower support needs are talking, and not just talking to other people, but also to themselves. And when you're talking to yourself, there's no one there to say, “Dude, take it easy, that's not so important.” When you're talking to yourself, you're inside an echo chamber. ACTr helps open the doors to that echo chamber, letting other people in to act as a filter to help you recognize that you're probably not going to be able to stop talking to yourself that way. However, there's another way of talking to yourself. Let's try that together and see if it helps change how you perform in the world.

What type of learner do you feel is ideal for ACTr?

Well, let's answer that question by saying, who are the easiest and who are the most difficult. I'll start with the latter. We're the most difficult. Let me ask you this—if you're an attorney who's the person that you dread most, walking through your door and saying, “I want to be your client.” I would say other attorneys, and you don't like other attorneys for clients because they're going to second guess everything that you say, since they know the law as well as you do. Likewise, the most challenging clients for ACTr are those who are highly verbal and adept with psychological theories. The people who are typically more receptive to ACTr are those with limited verbal skills. People with moderate support needs are well-suited for ACTr because they're frequently comfortable with humor and being a little bit silly, which helps in an ACTr context.

That’s interesting because among behavior analysts, there appears to be a misconception that ACTr is better suited for individuals with lower support needs than those with moderate or higher support needs. Are there any specific populations or individuals for whom ACTr might not be as well suited?

While ACTr can be beneficial for many individuals, since some verbal skills are required, ACTr cannot be effectively implemented with nonverbal learners. Nonetheless, this highlights some concerns in our field as we are growing in rank and numbers very rapidly and altering the style of education at the graduate level. One concern is that many practitioners have lost the thread of individualizing treatment for each person and their unique context. Meanwhile, if we're not individualizing treatment, we're looking for quick fixes. Additionally, despite analysis being a pillar of the science of behavior, many practitioners are neglecting the analysis portion of ABA. Instead, they’re looking for the book on the wall that has the protocol, thinking all I have to do is do what's in the book, instead of identifying what this human being right here would benefit most from uniquely and independently.

What behavioral challenges do you feel ACTr is well-suited to support? 

Any. The thing I think people get confused about is that ACTr should have its own set of goals, like maybe we should have a mindfulness goal or a diffusion goal. And that's not ACTr. That's not the way we do ACTr. We're behavior analysts and behavior analysts are interested in socially important, observable measurable behaviors. So whether it's self-injurious behavior or asking a person that you're attracted to out on a date or asking for this toy versus that toy, or reducing aggression towards others, any one of these are the stuff of ACTr, as well as the stuff of ABA. So, there's no particular behavioral challenge ACTr is well-suited to support.

What should parents expect from an ACTr practitioner? Are there any quality indicators or red flags you could share?

I think what you can expect from a good ACTr practitioner is that they remain focused on the observable, measurable, socially important goals that have always been part of the behavior analyst’s reason for being present in your life. An ACTr practitioner will also be interested in uncovering the ways that you, your staff, and your loved ones receiving services are talking to themselves. Ideally, an ACTr practitioner is asking questions about how you’re talking to yourself or how your child is talking to themselves—not how we're talking to each other, but how we're talking to ourselves privately. 

One red flag would be if you noticed that an ACTr practitioner is interested in changing thoughts and emotions—changing how you think or what you think or changing how you feel or what you feel. That's not ACTr, and it's not ABA. ACTr is not about making you feel better. It's about helping you feel better. That is, to welcome all the feelings and to be curious about them.

I do some coaching with competitive rock climbers who are part of a youth climbing team, and many times they get stuck inside of their heads just like competitive swimmers, baseball players, teachers, attorneys, and doctors. But climbing is a very physical activity, and there are many ways we can illustrate how climbers get stuck. One of the things we were just talking about is learning to feel better rather than trying to feel better during practice. What if you were to wear a small backpack and put little pieces of paper about each of your difficult emotions—I don't want to disappoint anybody. I want to be perfect—and have a way to get rid of these thoughts and emotions? I'm scared. I'm anxious about being watched by other people. When nobody's watching me, I climb really well, but when other people are watching, it's terrifying. Let's write all these down, put them inside of a small backpack, and put it on, because right now, here's what you're doing—you're trying to push those thoughts away. That will make you feel better, right? It will make you feel better to push them all away. What are you doing with your hands? Oh, yeah, you're pushing those thoughts. So, wait a minute—what are your hands supposed to be doing? Oh, yeah, I'm rock climbing. But wait—you can't be rock climbing because you have to be pushing, at least with one hand. But climb, because you don't want to disappoint those people, right?

Now, if you just put a backpack on with all those thoughts and emotions, you get to bring them along. And now you get to feel the texture of the rock. You get to feel better. You're still going to feel these things; I have no way of getting rid of them, but they're going to be right here with you on your back in your backpack. So, the other part of that is, what about the things I'm holding onto really tightly? I'm holding on to this thought that I have to be perfect. I'm holding on to the thought that I have to get an “A” in this class. I have to be the best in my class in climbing and in school, too.

What do kids have on the back of their backpacks? Everyone has keychain charms with these little things—kittens, puppies—Would you be willing to take them off and put them aside just for this one climb during practice? Or just for this one day at school? Or even just for this one hour? Would you be willing to put them in your locker, lock the locker, and walk through the halls without the kitty just for an hour, and see what happens? Because this kitty is just like your thought that you have to get an “A” or that they have to like you or if I'm too smart, people will hate me.

What is your definition of a good behavior analyst? 

To me, a good behavior analyst is one who is doing some of the things we talked about before—focusing on observable, measurable behavior that's socially important as their primary objective. Secondarily, they are able to approach thoughts and emotions, memories, and bodily sensations as part and parcel of what it is to be a human being, and not being dismissive or ignoring those things. A good behavior analyst is working with the individual in front of them—not with a textbook on their wall. A good behavior analyst is sensitive, but discriminating between situations where it's useful to listen thoroughly and situations where it's useful to ask permission to interrupt. A good behavior analyst is listening for when a person is doing everything because it's important to them and when they're doing things because it's important to somebody else. A good behavior analyst takes into consideration what is most important to address right now, and what can be put on the back burner until a more workable time, allowing us to focus on other things. The opposite of this is a behavior analyst who has 25 goals for a learner and requires their behavior technicians teach and take data on all 25 goals each session to ensure they’ve collected 45 data points an hour. It's a recipe for disaster. My clinical mentor, Jeff Kupfer, taught me to use the KISS rule: Keep It Simple. He also taught me that even if a behavior plan has all the bells and whistles, if nobody can do it, it ain't worth the paper it's written on.

What is one way neurotypicals can foster greater inclusivity for autistic individuals?

We now recognize April as Autism Acceptance Month rather than Autism Awareness Month. And it's a very important pivot in a way of languaging about what we're hoping to accomplish in the world. What we're hoping to accomplish is greater inclusivity. But acceptance in this context doesn't mean that we're going to accept that certain people don't have any skills. We're not going to accept that certain people are going to hurt themselves or damage property. It means we're going to engage in activities that produce belonging. 

There's a reason why language changes over time, because our values change over time, our ethics change over time, our sense of what's a just and fair environment and society changes over time. In the 1960s and 70s, there was an emphasis on normalization, followed by integration, and then inclusion. But even if we include people that doesn't necessarily mean that people feel belonging or welcome.

So how do we foster greater inclusivity?  

I think we develop ways to help people experience the capacity to contribute to each other's lives. Both individuals who receive services and their peers need to have this experience and benefit from this experience of contributing to each other to produce the context in which we belong and they belong. Once we're all fellow travelers on a magnificent journey we're able to make room for each other's weaknesses. We're able to help people get stronger and we're able to laugh about it at the end of the day and go to sleep saying they did what they could. We did what we could. That's a good day.

Can you recommend any resources for autistics, parents, or the providers who support them? 

My friend Russ Harris has written a number of extraordinary books. His first book was The Happiness Trap, followed by The Confidence Gap. In his third book, The Reality Slap, he writes about his experience with his new baby, who wasn't developing as expected by 12 months. He began investigating and found that the only empirically supported treatment for kids like his was applied behavior analysis. There was one clinic on the other side of Australia, where he lived, where they were practicing ABA with a broader understanding of the way people think and talk to themselves. Russ packed up his family and moved them 2,000 miles away to a small rural community where this clinic was operating, and 20 years later his kid is doing awesome. And Russ changed his career from being a physician in private practice to being a psychologist and has committed his life to helping parents and others develop skills for flexibility in their lives.

In addition to my book, ACT and Applied Behavior Analysis: A Practical Guide to Ensuring Better Behavior Outcomes Using Acceptance and Commitment Training, which is a step-by-step self-training manual, practitioners might also be interested in Acceptance and Commitment Therapy for Behavior Analysts and The Behavior Analyst's Guide to Working with Parents.

To learn more about Dr. Szabo’s work, visit ACT Now ABA. You can also connect with him on LinkedIn or by email at tom@ACTnowaba.com.

References

Kelly, A.D., & Kelly, M.E. (2021). Acceptance and commitment training in applied behavior analysis: Where have you been all my life?. Behavior Analysis in Practice, 15(1), 43–54. https://doi.org/10.1007/s40617-021-00587-3