Abstract
For behavior analytic practitioners, skills related to building a therapeutic alliance (e.g., empathic statements, reflective listening, affirmations) may be as important as knowledge of and skills in implementation of the science of behavior analysis. We surveyed 277 board certified behavior analysts (BCBAs) to learn more about their training, use of these skills, and their perceptions of how their skills might have changed over years of practicing. The findings suggest that behavior analysts may benefit from explicit training in skills required to establish and maintain therapeutic relationships with parents of children with autism. In this article we review recent research in this area and suggest directions for training of behavior analysts. Further, motivational interviewing is introduced as an evidence-based clinical approach that encompasses many of the skills required to build a therapeutic alliance.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data Availability
N/A.
Code Availability
N/A.
Notes
As described below, aspects of this relationship have been referred to in the behavior analytic literature as both behavioral artistry (e.g., Foxx, 1998) and compassionate care (e.g., Taylor et al., 2018), however, we use the term therapeutic alliance given the robust research on this topic in other fields.
References
Allen, M., Le Cook, B., Carson, N., Interian, A., La Roche, M., & Alegria, M. (2017). Patient-provider therapeutic alliance contributes to patient activation in community mental health clinics. Administration Policy in Mental Health & Mental Health Services Research, 44(4), 431–440. https://doi.org/10.1007/s10488-015-0655-8
Baer, D. M., & Wolf, M. M. (1987). Some still-current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 20(4), 313–327.
Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97.
Baier, A. L., Kline, A. C., & Feeny, N. C. (2020). Therapeutic alliance as a mediator of change: A systematic review and evaluation of research. Clinical Psychology Review, 82, 101921. https://doi.org/10.1016/j.cpr.2020.101921
Barnes, R. D., & Ivezaj, V. (2015). A systematic review of motivational interviewing for weight loss among adults in primary care. Obesity Reviews: An Official Journal of the International Association for the Study of Obesity, 16(4), 304–318. https://doi.org/10.1111/obr.12264
Barnett, E., Sussman, S., Smith, C., Rohrbach, L. A., & Spruijt-Metz, D. (2012). Motivational interviewing for adolescent substance use: A review of the literature. Addictive Behaviors, 37(12), 1325–1334. https://doi.org/10.1016/j.addbeh.2012.07.001
Barwick, M. A., Bennet, L. M., Johnson, S. N., McGowan, J., & Moore, J. E. (2012). Training health and mental health professionals in motivational interviewing: A systematic review. Children & Youth Services Review, 34(9), 1786–1795. https://doi.org/10.1016/j.childyouth.2012.05.012
Birnie, K. A., Hundert, A. S., Lalloo, C., Nguyen, C., & Stinson, J. N. (2019). Recommendations for selection of self-report pain intensity measures in children and adolescents: A systematic review and quality assessment of measurement properties. Pain, 160(1), 5–18. https://doi.org/10.1097/j.pain.0000000000001377
Bourke, E., Barker, C., & Fornells-Abrojo, M. (2021). Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis. Psychology & Psychotherapy: Therapy, Research & Practice, 94(3), 822–853. https://doi.org/10.1111/papt.12330
Burton, A. L., Abbott, M. J., Modini, M., & Touyz, S. (2016). Psychometric evaluation of self-report measures of binge-eating symptoms and related psychopathology: A systematic review of the literature. International Journal of Eating Disorders, 49(2), 125–142. https://doi.org/10.1002/eat.22453
Callahan, K., Foxx, R. M., Swierczynski, A., Aerts, X., Mehta, S., McComb, M., Nichols, S. M., Segal, G., Donald, A., & Sharma, R. (2019). Behavioral artistry: Examining the relationship between the interpersonal skills and effective practice repertoire of behavior analysis practitioners. Journal of Autism & Developmental Disorders, 49(3), 3557–3570. https://doi.org/10.1111/papt.12330
Carroll, K. M., Ball, S. A., Nich, C., Martino, S., Frankforter, T. L., Farentinos, C., Kunkel, L. E., Mikulich-Gilbertson, S. K., Morgenstern, J., Obert, J. L., Polcin, D., Snead, N., & Woody, G. E. (2006). Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug & Alcohol Dependence, 81(3), 301–312. https://doi.org/10.1016/j.drugalcdep.2005.08.002
Chadwell, M. R., Sikorski, J., Roverts, H., & Allen, K. D. (2019). Process versus content in delivering ABA services: Does process matter when you have content that works? Behavior Analysis: Research & Practice, 19(1), 14–22. https://doi.org/10.1037/bar0000143
Christopher, P. J., & Dougher, M. J. (2009). A behavior-analytic account of motivational interviewing. The Behavior Analyst, 32(1), 149–161. https://doi.org/10.1007/bf03392180
Croft, R. L., & Watson, J. (2019). Students clinicians’ and clients’ perceptions of the therapeutic alliance and outcomes in stuttering treatment. Journal of Fluency Disorders, 61, 1–10. https://doi.org/10.1016/j.jfludis.2019.105709
de Roten, Y., Zimmermann, G., Ortega, D., & Despland, J. N. (2013). Meta-analysis of the effects of MI training on clinicians’ behavior. Journal of substance abuse treatment, 45(2), 155–162. https://doi.org/10.1016/j.jsat.2013.02.006
Ekong, G., & Kavookjian, J. (2016). Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review. Patient Education & Counseling, 99(6), 944–952. https://doi.org/10.1016/j.pec.2015.11.022
Faustino-Silva, D. D., Meyer, E., Hugo, F. N., & Hilgert, J. B. (2019). Effectiveness of motivational interviewing training for primary care dentists and dental health technicians: Results from a community clinical trial. Journal of Dental Education, 83(5), 585–594. https://doi.org/10.21815/jde.019.063
Forsberg, L., Forsberg, L. G., Lindqvist, H., & Helgason, A. R. (2010). Clinician acquisition and retention of Motivational Interviewing skills: A two-and-a-half-year exploratory study. Substance Abuse Treatment, Prevention, & Policy, 5(1), Article 8. https://doi.org/10.1186/1747-597x-5-8
Foxx, R. M. (1998). Twenty-five years of applied behavior analysis: Lessons learned. Discriminanten, 4, 13–31. https://doi.org/10.1007/bf03393166
Heckman, C. J., Egleston, B. L., & Hofmann, M. T. (2011). Efficacy of motivational interviewing for smoking cessation: A systematic review and meta-analysis. Tobacco Control, 19(5), 410–416. https://doi.org/10.1136/tc.2009.033175
Hettema, J. E., & Hendricks, P. S. (2010). Motivational interviewing for smoking cessation: A meta-analytic review. Journal of Consulting & Clinical Psychology, 78(6), 868–884. https://doi.org/10.1037/a0021498
Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16. https://doi.org/10.1037/a0022186
Jaafar, N. H., Othman, A., Majid, N. A., Harith, S., & Zabidi, H. Z. (2019). Parent-report instruments for assessing feeding difficulties in children with neurological impairments: A systematic review. Developmental Medicine & Child Neurology, 61(2), 135–144. https://doi.org/10.1111/dmcn.13986
Kaltman, S., & Tankersley, A. (2020). Teaching motivational interviewing to medical students: A systematic review. Academic Medicine, 95(3), 458–469. https://doi.org/10.1097/acm.0000000000003011
LeBlanc, L. A., Taylor, B. A., & Marchese, N. V. (2019). The training experiences of behavior analysts: Compassionate care and therapeutic relationships with caregivers. Behavior Analysis in Practice, 13(2), 387–393. https://doi.org/10.1007/s40617-019-00368-z
Lee, Y., Yang, H.-J., Chen, V. C., Lee, W.-T., Teng, M.-J., Lin, C.-H., & Gossop, M. (2016). Meta-analysis of quality of life in children and adolescents with ADHD: By both parent proxy-report and child self-report using PedsQLTM. Research in Developmental Disabilities, 51–52, 160–172. https://doi.org/10.1016/j.ridd.2015.11.009
Lim, G., Park, I., Park, S., Song, S., Kim, H., & Kim, S. (2014). Effectiveness of smoking cessation using motivational interviewing in patients consulting a pulmonologist. Tuberculosis Respiratory Diseases, 76(6), 276. https://doi.org/10.4046/trd.2014.76.6.276
Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education Counseling, 92(2), 157–168. https://doi.org/10.1016/j.pec.2013.07.012
Madson, M. B., Loignon, A. C., & Lane, C. (2009). Training in motivational interviewing: A systematic review. Journal of Substance Abuse Treatment, 36(1), 101–109. https://doi.org/10.1016/j.jsat.2008.05.005
Madson, M. B., Villarosa-Hurlocker, M. C., Schumacher, J. A., Williams, D. C., & Gauthier, J. M. (2019). Motivational interviewing training of substance use treatment professionals: A systematic review. Substance Abuse, 40(1), 43–51. https://doi.org/10.1080/08897077.2018.1475319
Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R., Tonigan, J., & Moyers, T. (2018). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of Consulting Clinical Psychology, 86(2), 140–157. https://doi.org/10.1037/ccp0000250
Martino, S., Ball, S. A., Nich, C., Frankforter, T. L., & Carroll, K. M. (2009). Informal discussions in substance abuse treatment sessions. Journal of Substance Abuse Treatment, 36(4), 366–375. https://doi.org/10.1016/j.jsat.2008.08.003
Maslowski, A. K., Owens, R. L., LaCaille, R. A., & Clinton-Lisell, V. (2021). A systematic review and meta-analysis of motivational interviewing training effectiveness among students-in-training. Training & Education in Professional Psychology, 16(4), 354–361. https://doi.org/10.1037/tep0000363
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. Guilford Press.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (Applications of Motivational Interviewing). Guilford Press.
Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting & Clinical Psychology, 72(6), 1050–1062. https://doi.org/10.1037/0022-006x.72.6.1050
Modini, M., Abbott, M. J., & Hunt, C. (2015). A systematic review of the psychometric properties of trait social anxiety self-report measures. Journal of Psychopathology & Behavioral Assessment, 37(4), 645–662. https://doi.org/10.1007/s10862-015-9483-0
Moyers, T. B. (2014). The relationship in motivational interviewing. Psychotherapy, 51(3), 358–363. https://doi.org/10.1037/a0036910
Oliveira, C. S. R., & Huziwara, E. M. (2021). Motivational interviewing under a behavior analysis perspective. In S. M. Oliani, R. A. Reichart, & R. A. Banaco (Eds.), Behavior analysis and substance dependence: Theory, research, and intervention (pp. 193–204). Springer. https://doi.org/10.1007/978-3-030-75961-2_13
Ostlund, A., Wadensten, B., Kristofferzon, M., & Haggstrom, E. (2015). Motivational interviewing: Experiences of primary care nurses trained in the method. Nurse Education in Practice, 15(2), 111–118. https://doi.org/10.1016/j.nepr.2014.11.005
Pecukonis, E., Greeno, E., Hodorowicz, M., Park, H., Ting, L., Moyers, T., Burry, C., Linsenmeyer, D., Streider, F., Wake, K., & Wirt, C. (2016). Teaching motivational interviewing to child welfare social work students using live supervision and standardized clients: A randomized controlled trial. Journal of the Society for Social Work and Research, 7(3), 479–505. https://doi.org/10.1086/688064
Pontoppidan, M., Niss, N. K., Pejtersen, J. H., Julian, M. M., & Væver, M. S. (2017). Parent report measures of infant and toddler social-emotional development: A systematic review. Family Practice, 34(2), 127–137. https://doi.org/10.1093/fampra/cmx003
Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). Sustaining motivational interviewing: A meta-analysis of training studies. Addiction, 109(8), 1287–1294. https://doi.org/10.1111/add.12558
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, 12(3), 654–666. https://doi.org/10.1007/s40617-018-00289-3
Tollison, S. J., Lee, C. M., Neighbors, C., Neil, T. A., Olson, N. D., & Larimer, M. E. (2008). Questions and reflections: The use of motivational interviewing microskills in peer-led brief alcohol intervention for college students. Behavioral Therapy, 39(2), 183–194. https://doi.org/10.1016/j.beth.2007.07.001
Yakovenko, I., Quigley, L., Hemmeigarn, B. R., Hodgins, D. C., & Ronksley, P. (2015). The efficacy of motivational interviewing for disordered gambling: Systematic review and meta-analysis. Addictive Behaviours, 43, 72–82. https://doi.org/10.1016/j.addbeh.2014.12.011
Zendjidjian, X. Y., Auquier, P., Lancon, C., Loundou, A., Parola, N., Faugere, M., & Boyer, L. (2014). Determinants of patient satisfaction with hospital health care in psychiatry: Results based on the SATISPSY-22 questionnaire. Patient Preference & Adherence, 8, 1457–1464. https://doi.org/10.2147/ppa.s67641
Zilcha-Mano, S., Roose, S. P., Barber, J. P., & Rutherford, B. R. (2015). Therapeutic alliance in antidepressant treatment: Cause or effect of symptomatic levels? Psychotherapy & Psychosomatics, 84(3), 177–182. https://doi.org/10.1159/000379756
Zuccala, M., Menzies, R. E., Hunt, C. J., & Abbott, M. J. (2019). A systematic review of the psychometric properties of death anxiety self-report measures. Death Studies, 46(2), 257–279. https://doi.org/10.1080/07481187.2019.1699203
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethical Approval
Study approved by Endicott College and May Institute Institutional Review Boards.
Informed Consent
Informed consent was gathered for all participants.
Conflicts of Interest/Competing Interests
N/A.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Plattner, C., Anderson, C. Therapeutic Relationships in Applied Behavior Analysis: Current Status and Future Directions. Behav Analysis Practice 16, 1222–1230 (2023). https://doi.org/10.1007/s40617-023-00819-8
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40617-023-00819-8