Latest / Behaviour Speak with Ben Reiman / A Compassionate Approach to Exposure Therapy with Danielle Cohen

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A Compassionate Approach to Exposure Therapy with Danielle Cohen · Behaviour Speak with Ben Reiman

• 0:01
  Okay, Danielle, welcome to Behaviour Speak.
• 0:04
  Thank you.
• 0:05
  Excited to have you before we get started.
• 0:07
  I just want to acknowledge I am producing this podcast on the territories of the Tla'amin, Klahoose, Homalco, and K'omoks First Nations and as always I'm grateful to be here.
• 0:17
  So let's start by learning a little bit about you and kind of how you got into the field, how you found ABA.
• 0:24
  Tell me a little bit about that, your origin story as it were.
• 0:27
  Yeah, absolutely.
• 0:28
  So I feel like I had a little bit of a funny start jumping into this field.
• 0:33
  I actually just had a friend, I was working at a Little Caesars pizza shop making pizzas and I had a friend reach out to me and they were like, hey, we have this job, there's an
• 0:42
  opening, it pays above minimum wage.
• 0:44
  And I was like, yes, sign me up.
• 0:46
  Like that sounds fantastic.
• 0:48
  And I ended up working in a special needs classroom at a school as a paraeducator.
• 0:53
  And from there I met my first BCBA.
• 0:57
  who really started to come in, would have us do certain things, and I was just in awe of the behaviour change that I saw and I was like, wow, this stuff really works.
• 1:07
  Like, this is amazing.
• 1:08
  Like, these kids are doing fantastic and they're having a good time and they're learning all these skills.
• 1:13
  And I was like, what is this?
• 1:14
  You know, and so he was like, you should go to school for this.
• 1:19
  And so I really just fell in love with it.
• 1:21
  I dropped everything.
• 1:23
  I went to school for it.
• 1:24
  I just started studying it and I really
• 1:27
  been doing it ever since.
• 1:28
  And so I've kind of gotten a little taste of what this looks like in the school setting, the clinic setting, the home setting.
• 1:35
  So it's been a really fun experience getting to dive right into this field and get to where I am now.
• 1:44
  I hear a lot of folks kind of tell that story.
• 1:47
  They work a job for a little bit and suddenly do a master's degree.
• 1:49
  How long were you doing the work before you jumped into graduate education?
• 1:56
  So I think I worked at that school for about four years and I think I left right when I started my master's so that I could have a little bit of a more flexible schedule and go
• 2:07
  to school and all of that.
• 2:10
  yes, but during that time I was finishing up my bachelor's too.
• 2:13
  So I was like, I gotta get this done so I can go study all this fun stuff in my master's program.
• 2:18
  So I was in it for a little while prior to graduate studies.
• 2:22
  Right on, right on.
• 2:23
  So definitely an upgrade from Little Caesar's then, Yeah, right on.
• 2:30
  And so we're talking about, this is uh the second, sorry, the third episode in a series we're doing on behaviour speak on the constructional approach.
• 2:41
  And we're gonna be talking a lot about constructional exposure therapy and we'll get into all that pretty soon.
• 2:47
  Tell me about how you discovered the constructional approach and what stood out for you in the beginning.
• 2:57
  Yeah, so my first just kind of exposure to the constructional approach was actually a talk given by Anna Linnehan and Sheila Klick.
• 3:08
  I want like many, many years ago, maybe 2021, I want to say.
• 3:13
  And they were giving this presentation on assent at ABAI.
• 3:16
  And I remember I had gone to like every assent talk I could find because I felt like this was such an important topic that our field was really pushing to the forefront of our
• 3:25
  conversations.
• 3:27
  And the way that they discussed it and the way that they were talking about it clicked for me.
• 3:32
  And I was like, this is what I feel like I've been waiting for.
• 3:34
  This makes so much sense.
• 3:36
  I feel like I can take this applied
• 3:38
  practice right away and use it to really support making our practices better and our teaching procedures better.
• 3:46
  And so that was a big turning point for me.
• 3:50
  And then my good friend who I worked with at the time, Dr.
• 3:53
  Angela Fuhrmann-Knowles, she began to study under Dr.
• 3:57
  Joe Layng who
• 3:59
  is one of the core people in the constructional approach.
• 4:04
  And so he began teaching her and on the side she was like, oh, I learned this, I learned this.
• 4:09
  And she was kind of teaching me after class and I really just got hooked.
• 4:13
  And so I was like, okay, well, I need to go study with Joe as well.
• 4:17
  And yeah, just have been reading every article that that group has been publishing and seeing their talks at conferences.
• 4:24
  And now I'm very close with a lot of members of that group.
• 4:27
  Hmm.
• 4:28
  yeah, so I really got hooked from the beginning and I've just been so interested in this line of research and this orientation towards um behaviour change.
• 4:38
  Right on.
• 4:38
  And just going back to 2021, you're at ABAI.
• 4:43
  What was it, what was happening back then that got you so interested in learning about Asset?
• 4:50
  What was happening in your life and kind of in your work that you were like, I need to know more about this stuff.
• 4:56
  Yeah, I at that time worked, I think it was either in home or in clinic, it was all within the same company and I was working with...
• 5:07
  all children, between like three and maybe eight years old at the time, autistic children.
• 5:14
  And so I knew from my master's program that the field was pushing towards a more like socially valid approach.
• 5:21
  And we were constantly as a field just evolving and pushing our science forward and looking towards more effective and efficient and compassionate procedures.
• 5:30
  And I felt like a big piece of that was understanding assent as this, you know, agreeable
• 5:37
  response, but also how as the person who's responsible for setting up the environment, setting it up in a way where someone can genuinely assent to that activity that we're
• 5:49
  presenting to them.
• 5:50
  And what do we do when they withdraw their assent?
• 5:53
  And what do we do when they give their assent?
• 5:55
  And I think that that talk specifically gave me so many answers that I had been looking for that.
• 6:02
  Yeah, I was just very appreciative that they took the time to come out to ABAI and share that with everybody.
• 6:08
  Right on, right on.
• 6:09
  And so you connect with Angela and then you connect with Dr.
• 6:15
  Joe Layng and you're starting to learn a lot more about this constructional approach.
• 6:20
  What felt different from the ABA that you had already experienced?
• 6:26
  Yeah, I think there's many things that I've noticed.
• 6:30
  I mean, it's all based on the same principles of behaviour, right?
• 6:33
  Our foundations are the same.
• 6:35
  I think it's genuinely just the orientation or the approach that is taken um that kind of shifts how we look at behaviour and how we then act towards changing behaviour.
• 6:48
  And I think that that small but kind of big shift made a big difference for me.
• 6:53
  And I know Awab in one of your previous episodes kind of went
• 6:56
  into a deep dive of this.
• 6:58
  So I don't want to reiterate everything that he said, but...
• 7:00
  um
• 7:03
  There was a few key pieces of the construction approach that stuck out most to me.
• 7:07
  um One is that they never aim to decelerate behaviour or eliminate behaviour.
• 7:13
  They're really looking at what behaviour, the absence of which is the problem.
• 7:17
  And then they specify, okay, this is the skill or the repertoire that we're gonna teach that's gonna allow this person to get all their critical reinforcers at maybe a lesser
• 7:28
  cost than what they are getting right now.
• 7:31
  Hmm.
• 7:33
  I thought that that was amazing and the uh way that they discuss assent is really based off of Israel Golddiamond teachings back in the 70s and he described it as genuine consent
• 7:45
  and kind of laid out this whole foundation um giving more
• 7:50
  context around what freedom looks like by accessing multiple alternatives that will get you your critical consequence and how that has this kind of inverse relationship with
• 8:01
  coercion.
• 8:02
  And when you're restricted in your alternatives, you're really coerced into responding in maybe one way to get this thing that you want.
• 8:09
  And I was like, man, that makes so much sense.
• 8:11
  Like, yeah, it was very interesting to me.
• 8:14
  So I, again, I was just hooked from the beginning.
• 8:18
  I love that.
• 8:20
  Before we get into CET, there's a term you use that Madura used quite a lot in her episode that I haven't heard before.
• 8:31
  We talk a lot about reinforcement and reinforcers and that sort of thing.
• 8:34
  But this phrase, critical reinforcer, is new to me.
• 8:38
  What's that mean?
• 8:39
  What's that about?
• 8:40
  So this is also a term that I believe comes from Israel Golddiamond and the critical reinforce or the critical consequence is going to be the consequence that governs the
• 8:52
  contingency.
• 8:53
  And so I think another way of saying that is let's say that you are a young kid that is really wanting the tablet.
• 9:02
  and you're like, my gosh, I really wanna play my tablet, this is my favorite thing.
• 9:07
  Well, the critical consequence there is gonna be that tablet.
• 9:11
  And so if I set it up to where I'm like, hey, if you complete your math homework, you can then go play on your tablet, that gives you one way to access what we would call the
• 9:21
  critical consequence or your tablet.
• 9:23
  Hmm.
• 9:23
  And let's say I say, but I'm going to give you a choice.
• 9:25
  I'm going to say you can do your math homework and get your tablet or you can do your English homework and get a cookie.
• 9:32
  Now we might think of a cookie as like a positive reinforcer.
• 9:35
  This is this great thing.
• 9:36
  Kids love cookies, but the critical consequence is not the cookie.
• 9:41
  The critical consequence is the tablet because that's what they want in that moment.
• 9:45
  They are working to get the tablet.
• 9:47
  And so I think in
• 9:49
  when we start talking about creating alternatives that are going to access that critical consequence, we're talking about alternatives that are going to all lead to that
• 9:58
  Mmm.
• 9:59
  that desired outcome of the tablet.
• 10:01
  So a true alternative, uh what we might call like a degree of freedom, would be you can do your math homework to get the tablet, you can do your English homework to get the tablet,
• 10:11
  you can do your chores to get the tablet, because those are all going to access you your critical consequence, which is what you're actually looking for.
• 10:20
  And I think that's that slight distinction between just any reinforcer or any consequence.
• 10:26
  But we're really talking about the consequence
• 10:28
  that governs the contingency.
• 10:31
  Interesting.
• 10:31
  Okay.
• 10:33
  Let's get into CET, Constructural Exposure Therapy.
• 10:37
  Kind of start simple.
• 10:38
  What is Constructural Exposure Therapy in plain language?
• 10:42
  Yes, I think that's a great question.
• 10:44
  um
• 10:46
  Constructional exposure therapy really is an intervention that is used in contexts that typically evoke really fearful or maybe aggressive behaviors.
• 10:57
  Behaviors that someone engages in to get distance or escape from some aversive thing in the environment.
• 11:03
  And so CET or Constructional Exposure Therapy is used to uh teach the behaviour, the absence of which is the problem.
• 11:13
  So said another way, we're going to go in during the assessment
• 11:16
  phase of CET and figure out, okay, what skill or behaviour is needed in this specific context that's going to allow you to get that same critical consequence, but at a much
• 11:29
  lesser cost than maybe these fearful or aggressive behaviors are costing you.
• 11:34
  Because I think we all know that uh those types of behaviors can be really costly.
• 11:39
  They can cost us relationships, they can cost us access to things like education or even medical care.
• 11:46
  So those types of responses, while very rational and make a lot of sense, can be really costly to the person.
• 11:53
  And so CET is really used to help teach a skill that's going to, again, get that same critical consequence, but without all those associated costs.
• 12:03
  And so what it looks like is we will kind of map out an interconnected chain.
• 12:08
  And so an interconnected behaviour chain consists of the behaviour of two different organisms.
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  So really like the implementer and the learner.
• 12:15
  in which the behaviour of one individual will serve as both the consequence and the SD for the behaviour of the other.
• 12:22
  So it's really like this back and forth interaction that is going to just be mapped out of whatever that skill is we determined is the most ecologically relevant response that is
• 12:33
  gonna support that learner.
• 12:35
  and again getting that critical consequence at a lesser cost.
• 12:39
  And the way that we teach that skill within CET is through shaping with negative reinforcement.
• 12:45
  And this is something that I found so profound when I was first learning about CET is
• 12:53
  the consequence that negative reinforcement contingency or that escape or distance from that aversive thing that's already maintaining all these behaviors, the uh fearful
• 13:04
  behaviors, the aggressive behaviors, that same consequence is now used to shape up this new response that is going to allow this person to more successfully navigate this
• 13:15
  environment at a lesser cost.
• 13:17
  And so,
• 13:19
  In a nutshell, feel like that was a long explanation, but that is what CET is.
• 13:25
  And that escape or that distance from the aversive thing is always made available in multiple different ways.
• 13:31
  So we are making it available not only for that fearful behaviour or the aggressive behaviour, but we're also making it available for meeting that criteria along that shaping
• 13:42
  procedure.
• 13:43
  And we'll shape along that interconnected chain to help develop that new skill.
• 13:49
  And that seems to be a key point in CET and constructional approaches in general is that there's multiple pathways to that critical reinforcer.
• 13:58
  Yeah, and I think that's how how Linnehan and colleagues will talk about genuine assent, that there's multiple ways to access that critical consequence.
• 14:06
  And that's how we can truly start assessing whether someone is agreeing to that activity or not, because they have other alternatives, but they're choosing this one.
• 14:16
  And so I think that's where we start to incorporate some of those teachings into this procedure.
• 14:21
  Yeah, I'm looking forward to learning more about that.
• 14:23
  actually have Angela Fuhrmann-Knowles coming on.
• 14:25
  uh I actually participated in her current study.
• 14:30
  uh And it was the first time I've heard sort of genuine versus apparent assent and genuine versus apparent consent.
• 14:39
  And then, of course, the idea of compulsion.
• 14:40
  uh Really fascinating areas.
• 14:42
  uh And I'm looking forward to kind of digging more into that with her.
• 14:46
  Really cool.
• 14:48
  So.
• 14:51
  Exposure therapy is not new.
• 14:53
  Why isn't traditional exposure therapy enough?
• 14:57
  Well, I don't know if I would say it's not enough.
• 15:00
  I think there's a long line of research on gold standard procedures like systematic desensitization, graduated exposure, things like that.
• 15:09
  And those procedures have been very effective in supporting people with very fearful behaviors for many, many years now.
• 15:19
  And so I wouldn't say that this is a better approach or anything like that.
• 15:25
  What I would say is this is an alternative
• 15:27
  to those approaches.
• 15:28
  And one of the reasons that I have liked this approach more when actually working and implementing it is that
• 15:38
  The amount of distress that's caused when we're working on these, honestly, very distressing behaviors is because we always have the option to opt out, because we always
• 15:48
  have the option to get that escape or distance in multiple different ways.
• 15:53
  We never require the person to kind of get to a certain point to get out of what's happening.
• 16:00
  And so that really keeps things at a very calm level while we are teaching these skills.
• 16:05
  And I think that I just appreciate the
• 16:07
  lack of distress while we're teaching these things.
• 16:10
  um And it's just something that we are constantly trying to research and refine.
• 16:16
  um you know, I think that that's science in general.
• 16:19
  We're always trying to evolve and learn more, try to create more effective and efficient procedures.
• 16:26
  And I think that's one of the things we're doing with this procedure.
• 16:30
  And now know you're a doctoral student and an academic and learning a lot about these things.
• 16:37
  I think in some ways, because of the work you're doing and being collegial and all that, you can't say things like this is better or this is worse.
• 16:46
  And you want to avoid terms like that.
• 16:47
  But I really don't know how a procedure that results in way less distress than another procedure isn't better.
• 16:56
  And so, you know, I think it will be interesting down the road to see if there's more comparisons and more measures around sort of levels of distress.
• 17:07
  And I'm actually curious, and I don't want to tangent too far, but I'd be curious to know if in traditional exposure therapy and graduated exposure therapy, because I think this is
• 17:18
  something that uh I'm digressing probably too much here, that
• 17:24
  In our field, we've talked a lot about social validity, uh maybe not have, but recognize that we haven't done a great job over the years of making that an important part of all of
• 17:37
  our studies uh and looking at some of the, you know, from some of the criticisms of our field around some of maybe the negative side effects of some of the things we do.
• 17:47
  uh
• 17:50
  I wonder if there has even been that kind of work to sort of look at levels of stress during exposure therapy and whatnot and kind of how that might be compared.
• 17:58
  Have you seen anything like that or?
• 18:01
  I do know that there is some research out there that speaks to um participants dropping out of studies that we can insinuate, maybe because of distress, maybe because of other
• 18:13
  things.
• 18:13
  I think people drop out of studies for a variety of reasons.
• 18:16
  um I know Awab and Jillian Baldwin and Justin Leaf put out a systematic literature review that was looking at exposure therapies.
• 18:28
  I want to say that came out in 2023,
• 18:31
  Okay.
• 18:31
  they speak to a lot of those things that across the literature, what trends we're starting to see.
• 18:38
  And that has been a basis of where we're trying to shift things when we're working on constructional exposure therapy.
• 18:45
  I apologize I don't have all the statistics memorized, but it's a great resource to look at.
• 18:51
  No, very good.
• 18:51
  Yeah, and we'll link to that article in the show notes.
• 18:54
  That's great suggestion.
• 18:58
  Maybe we can talk about that a little bit more in terms of how CET differs from systematic desensitization.
• 19:07
  Can you tell me a little bit about that?
• 19:09
  Yeah, I think in general there's some differences.
• 19:12
  I think it's easy to pull out maybe one or two examples because the literature base for systematic desensitization and graduated exposure is so large that there's all these
• 19:23
  different variations of the procedures and the outcomes.
• 19:29
  so I might say, you know, here's some general differences and you might be able to pull an article that's like, no, they did this.
• 19:34
  um But I think the general procedures for things
• 19:38
  like systematic desensitization are they will
• 19:43
  teach first a relaxation technique.
• 19:45
  So they'll be like, here's what you can do to help relax.
• 19:49
  And then they create a fear hierarchy.
• 19:51
  And so they work in collaboration with the client to basically create a hierarchy of here's the least fearful thing, here's the most fearful thing.
• 19:59
  Now let's build every step in between.
• 20:02
  And then the exposure piece of it, whether that's in vivo exposure or images or imagination, whatever it may be.
• 20:10
  And they work their way up from the least fearful thing all the way to
• 20:13
  the most fearful thing while prompting them to use those relaxation techniques.
• 20:18
  oh
• 20:20
  whenever things start to escalate during those exposures.
• 20:25
  And so I think the intention in systematic desensitization is to try and avoid distress as you are progressing and to make small enough steps that you are not producing distress in
• 20:36
  the client as you are working on these things.
• 20:39
  But I think some of the differences in constructional exposure therapy are, uh
• 20:46
  One, we're not necessarily just trying to eliminate the fear or the aggression.
• 20:51
  Our goal is never to reduce behaviour or eliminate behaviour.
• 20:54
  Our goal really is to specify what behaviour, the absence of which is the problem, what behaviour is going to produce that critical consequence at a lesser cost and how can we
• 21:06
  then teach that skill, strengthen that skill, or transfer that skill to this context.
• 21:11
  And in the procedure that we used to teach it, we're also
• 21:16
  breaking it down into small steps which is what shaping essentially is, but we are providing that distance and escape in multiple ways.
• 21:24
  And I think that that's another key difference too is typically in systematic desensitization you're going to continue to progress forward through the procedure if
• 21:31
  they're calm, but us if you are engaging in that skill that we're trying to teach and you are not in distress we're still going to remove.
• 21:40
  uh that aversive item, we're still going to provide that distance as the reinforcer for you engaging in that skill set.
• 21:47
  And so I think those are two big differences that I have noticed.
• 21:52
  And again, some procedures may use those, but I think the majority don't.
• 21:57
  And so that's some of the differences that I'm seeing in these procedures.
• 22:00
  Mm-hmm.
• 22:02
  No, I like that.
• 22:04
  And I like that distinction of, with desensitization, there's that, like you said, that fear hierarchy and just sort of, you know, I imagine the uh sort of the, I think about
• 22:18
  examples like people like fear of snakes and fear of dogs and starts with photos and eventually it's, you know, videos and eventually it's, you know.
• 22:29
  the dog in the kennel and then the dog getting closer and closer.
• 22:32
  um And in the end, it's someone standing in front of this dog that's growling away and doing really scary things.
• 22:41
  Whereas exposure therapy is, or CET is sort of saying...
• 22:51
  What's the long-term goal here?
• 22:53
  And what sort of skill?
• 22:55
  The skill isn't to be able to approach incredibly violent dogs and stand there and uh engage in relaxation, in sort of relaxation or whatever, behavioral relaxation therapy or
• 23:09
  whatever.
• 23:11
  The goal might be to...
• 23:12
  um
• 23:15
  you know, be able to walk past the dog and, you know, safely or I suppose in that particular context, we might be using CET also on the dog so that we can get the dog to
• 23:29
  chill out a bit too.
• 23:31
  But it's not just about exposure to fear, exposure to fear.
• 23:35
  Yeah, and I think that is such a good point, Ben.
• 23:38
  Really the emphasis is we are teaching and shaping along that terminal goal we have for them.
• 23:46
  So in the example with dogs, let's say we're just scared of even just very calm, nice dogs, and we kind of do everything we can to get distance and get away from any dog.
• 23:58
  Well, the skill set might be, I want to be able to go to my friend's house that has a dog and play games with them.
• 24:04
  And so in order to do that, I have
• 24:05
  to be able to walk past the dog and sit down at the table and play board games with my friends.
• 24:11
  Well, we would teach along that specific skill, the walking past, right, slowly approaching and then slowly passing the dog.
• 24:20
  And we would teach along that skill.
• 24:22
  Now, I think that that also might be a distinction when we're looking at systematic desensitization, where our procedure and our shaping procedure has to do with that
• 24:33
  specific repertoire, where
• 24:35
  uh A lot of the time, because systematic desensitization, the goal is just to eliminate the fear.
• 24:41
  We will go through things like imagining or using images or things like this that don't necessarily connect to the actual skill set of I'm going to engage in these movements to
• 24:51
  produce this outcome in this context.
• 24:55
  And so that's another just slight difference between these procedures.
• 25:00
  Right on.
• 25:01
  Earlier referenced shaping with negative reinforcement.
• 25:04
  This was a concept I first heard from Awab at the last Endicott conference, which it uh was a completely new concept to me.
• 25:15
  And I think in some ways when he was introduced to it, it was new to him as well.
• 25:20
  What does shaping with negative reinforcement, you've touched on it already, but really mean and sort of how does it differ from coercion and escape extinction and things like
• 25:30
  that?
• 25:31
  Sure.
• 25:31
  So I...
• 25:33
  I a lot of behaviour analysts use shaping quite regularly, right?
• 25:37
  And we use shaping by reinforcing successive approximations towards some terminal goal.
• 25:45
  And the way that that usually works is I'm gonna take one small step that's closer to this goal and maybe I get like an M And then I take another step closer to this goal and I get
• 25:53
  an right?
• 25:54
  Whatever that skillset may be.
• 25:56
  And in that context, that is gonna function as a positive reinforcer.
• 26:01
  Now, the only difference when we're talking about shaping
• 26:03
  with negative reinforcement is we're still taking those small approximations, those small steps towards this terminal goal, but instead of providing an &M, we're removing whatever
• 26:15
  aversive stimulus is in the environment and that is going to function as the reinforcer for those approximations.
• 26:22
  And so the only slight difference there is essentially the reinforcer.
• 26:29
  And I think that the differences between things like escape extinction or um those types of things is...
• 26:37
  uh That would still be dependent on the procedure.
• 26:39
  So again with CET, we never would use extinction.
• 26:42
  We never would withhold the consequence of being able to escape or avoid this aversive thing.
• 26:48
  What we are doing is making that available in multiple ways.
• 26:51
  Because I think if someone is choosing to opt out, if they're like, nope, I can't do this.
• 26:55
  I'm going to step away.
• 26:56
  I'm going to get that distance and not meet this current shaping step.
• 27:00
  That's just information to the implementer of like, okay, I just need to change my procedure.
• 27:06
  I need to
• 27:07
  adjust it in a way that's going to allow this person to be successful in this context and that might mean I need to adjust some things and I think that that's okay.
• 27:15
  I think those opt-out responses can be really informative and I'm not trying to get you to opt out less.
• 27:22
  I'm trying to understand why you're opting out and then change the environment.
• 27:26
  And I think this may be hard for behaviour analysts to sort of grasp, I think, as being a good thing to do.
• 27:40
  And I think also it might be tough for parents as well, because we often hear the sort of, I don't know if there's any evidence behind it.
• 27:48
  I think it's a bit of a myth, but we hear this idea that if we reinforce
• 27:56
  problem behaviour in some way in our intervention, then we're gonna make things worse.
• 28:01
  And so if we allow the individual to escape when they engage in interfering behaviour or distressing behaviour, we're reinforcing the interfering or distressing behaviour and
• 28:13
  therefore, and isn't that a bad thing?
• 28:16
  What do you kind of say to folks when they have that argument?
• 28:20
  I think it's a really fair concern.
• 28:23
  I've definitely heard that before.
• 28:24
  I've definitely had conversations around that before.
• 28:28
  And I think I would share that same concern if we stopped with, okay, they opted out.
• 28:34
  I'm never doing this again.
• 28:36
  Because I don't think that that's so helpful.
• 28:38
  If we've already determined that this skill is so important to work on, that it's gonna benefit this person's life, that they're in collaboration, they're on board, it's just
• 28:46
  tough.
• 28:46
  uh
• 28:49
  I would agree if we stopped at that point.
• 28:51
  I don't think that that would be helpful.
• 28:53
  But what I am talking about in this procedure, and I think the way that we tend to discuss this within the constructional approach is if someone is opting out, if they're
• 29:04
  withdrawing their assent, uh yes, we stop it in that moment because that's the most compassionate thing to do.
• 29:10
  I'm not going to push you through it.
• 29:11
  I'm not going to force you to escalate for me to then still give you that same consequence.
• 29:16
  I'm going to honor what you're telling me.
• 29:18
  But then I'm going to use that information to change my procedure to make it so that you do want to opt in.
• 29:26
  I can adjust things in the activity.
• 29:28
  I can adjust things in a way that are going to allow you to agree to participate in a way that's not coerced because you always have the option to still opt out.
• 29:37
  But I can keep making things better for you so that we're teaching in a context where you can truly learn.
• 29:43
  And I think that that once we are seeing that occur in action,
• 29:48
  and we are understanding that opting out doesn't mean we're done teaching.
• 29:53
  It means we're just giving them a break for a moment and we're working together to make changes that are necessary.
• 29:59
  That kind of concern that people have tends to fade away.
• 30:08
  Let's get some examples.
• 30:09
  Let's hear a little bit about uh what this all looks like in practice.
• 30:14
  A lot of folks listening are familiar with uh one of your cases, the nail clipping case.
• 30:21
  It came up at the Innecon conference.
• 30:25
  A lot of folks talking about it.
• 30:27
  I think...
• 30:28
  everybody I've interviewed so far about the constructional approach references Danielle's nail clipping case and how interesting that is.
• 30:35
  And through that, in some ways, we've all talked about that case in a variety of different ways.
• 30:41
  So I wouldn't mind getting into some other examples.
• 30:44
  Maybe you start us with any one that comes to mind and walk us through what this approach looks like from the beginning.
• 30:53
  Yeah, so I think another one that I tend to present on is a blood draw that I have supported learners with, and I think that this is a good example because with nail
• 31:06
  clipping, there's no painful end to it.
• 31:10
  Mm-hmm.
• 31:11
  don't know about you, I don't enjoy getting my blood drawn.
• 31:14
  uh It is painful, they are sticking with a needle, I still get a little nervous when going.
• 31:20
  So I think that this approach is not just useful for things that have ah maybe an easier ending, but also for things that can be painful or uncomfortable or things like that.
• 31:32
  And we can still support individuals.
• 31:35
  engaging in those types of activities that are really tough and are uncomfortable and still teach them to participate in a way that's not going to be coercive or distressing.
• 31:47
  Hmm.
• 31:48
  So, yeah, I had a learner, I want to say they were about 11 years old when their parent came to me saying, you know, we need to get this blood drawn.
• 31:57
  The doctor has been requesting it.
• 31:59
  We've tried a few times and we haven't been successful.
• 32:03
  You know, as soon as we get there, we don't want to go in the building.
• 32:06
  Once we're in the building, it's a whole fight to get out of the room.
• 32:10
  And the nurses and the phlebotomists are just unable to safely
• 32:15
  get the blood draw.
• 32:16
  And I was like, okay, so this is where I reviewed the procedures of constructional exposure therapy with them and I got their consent.
• 32:25
  And this is a learner who has a decent amount of language.
• 32:30
  There's still some things that I think needed to be shown rather than explained to make sure they knew what they were agreeing to and things like that.
• 32:37
  um
• 32:39
  But what we did is we gathered common materials that are used for a blood draw.
• 32:43
  So I was decked out in scrubs.
• 32:46
  I had a tourniquet and we had a syringe that looks very similar to the ones that are used at the doctor's office.
• 32:55
  We had alcohol swabs and band-aids.
• 32:57
  We had a lot of the common stimuli that are used in this medical procedure.
• 33:03
  And we brought that to the learner's house.
• 33:05
  And we first just taught them
• 33:08
  how this works.
• 33:09
  You can ask at any point for a break.
• 33:11
  We're gonna honor that.
• 33:13
  get distance from these materials.
• 33:15
  You can walk away, no problem.
• 33:16
  um If you show us any indications of distress, we're done.
• 33:21
  We're gonna stop.
• 33:22
  We're gonna take everything off and you're gonna get to walk away.
• 33:25
  um Or if you meet our current goal, we're gonna take everything off and you get to walk away.
• 33:30
  And so in this instance, there was three different ways to get that distance or escape.
• 33:35
  And so that was known ahead of time.
• 33:37
  And what we did is we built that interconnected chain.
• 33:40
  So we planned this out from the beginning.
• 33:42
  What skill do we need to teach him?
• 33:45
  That absence of which is the problem.
• 33:47
  And so what was needed in this context was to be able to walk into the doctor's office, go in, sit down, put your arm out and hold it still for quite a long period of time.
• 33:57
  Like it takes a minute to actually get that all done.
• 34:00
  And so we're like, OK, these are the skills that are needed.
• 34:04
  and for our shaping procedure we started from the beginning of that.
• 34:07
  So we started just with walking over with some of the materials visible on the table.
• 34:12
  Hmm.
• 34:13
  He came, he sat down, we were like, great job, get out of here.
• 34:17
  Like, let's go, let's go take a break.
• 34:19
  And so each step we would add one step of the blood draw routine.
• 34:25
  So next he would come over and we'd ask him to put his arm out.
• 34:28
  The next step we'd have him come over, put his arm out, roll his sleeve up, and maybe we would put the tourniquet on.
• 34:34
  And that was a tough one.
• 34:36
  And so we had to start with maybe draping it over his arm at first, then loosely tying it, then actually tying it at the tightness
• 34:43
  that they would need to do for the procedure.
• 34:46
  We then the next time he came over would add in the alcohol swab and we got to the point where he would meet each step.
• 34:55
  he would get that distance, we'd give him about a two minute break, and then we would come back to the table again.
• 35:01
  And so he is willingly walking up to the table, sitting down, putting his arm out.
• 35:06
  And the amount of distress that we were seeing was was minimal.
• 35:12
  Prior to this, when we had just done our baseline trials, he would come sit down.
• 35:16
  As soon as he saw the materials, he like jumped up out of a seat and was like, this is a blood draw?
• 35:20
  No.
• 35:21
  And started to move away.
• 35:23
  And now he's coming over.
• 35:25
  sitting down.
• 35:25
  he's putting his arm out.
• 35:28
  And so we were able to get through the whole setup and then we got to the point where we actually wanted to introduce the syringe um into the routine.
• 35:36
  And so we had started with an empty syringe where there was no cap and no needle in there and he did pretty good with that and then we added the cap and that was a little
• 35:48
  That was a lot.
• 35:48
  So we had to take a step back and we increased the duration that we were doing with an empty syringe first.
• 35:55
  Then we were able to add the cap back in because he got a little bit more used to the syringe being present and touching his skin.
• 36:02
  Then we were able to add the needle in and we would just do a touch for one second and provide that break.
• 36:08
  And then we do a touch for two seconds and we'd provide that break and then three seconds.
• 36:12
  And we kind of worked our way up until we got to the point where he was
• 36:17
  rocking over to the table, putting his arm out.
• 36:20
  We got to do the tourniquet, the alcohol swab.
• 36:23
  We held the syringe with the needle on his skin.
• 36:25
  Now we weren't piercing the skin at home.
• 36:27
  This is not our area of expertise, but he could still feel it.
• 36:31
  Like that feeling and that sensation is still there.
• 36:33
  And we were able to do that between 30 and 60 seconds across multiple trials before his mom then took him back to the doctor's office and he was successfully able to get an
• 36:44
  actual blood draw.
• 36:46
  And what was really cool is
• 36:47
  Mom did it, I want to say like 200 days later.
• 36:51
  Like he needed a follow-up blood draw and without any additional practice or without any follow-ups, he again went back and had a completely successful blood draw.
• 37:01
  Hmm.
• 37:03
  I think in total that took about six hours.
• 37:06
  It was a little under two hours of actual shaping steps and most of that time was just the breaks in between where we were removing the stimuli and giving him some time away from
• 37:18
  it.
• 37:19
  And so that six hours, is that one day?
• 37:25
  We broke this up over four days.
• 37:28
  Four days, okay.
• 37:30
  Amazing.
• 37:32
  And so you get them to the point of accepting the needle tap.
• 37:39
  And then there was, because I think I'm thinking about sort of that fear exposure hierarchy we talked about with sort of traditional exposure therapy.
• 37:51
  Initially, you couldn't even get him through the doors of the clinic uh before he sort of ran away in bulk.
• 37:58
  Did you have to do any exposure in the actual clinic setting or did mom just take him?
• 38:03
  walked in, no problem, and blood draw happened?
• 38:08
  Yeah, so we were prepared for that.
• 38:10
  So mom was going to go take him.
• 38:12
  If there was any barriers, we were going to work with the doctors to then go in and follow up with some CET at the medical office.
• 38:20
  But it wasn't necessary.
• 38:22
  He was able to just go in the next time that mom took him and had a successful blood draw without distress.
• 38:29
  So, yeah.
• 38:31
  that's incredible.
• 38:32
  And did you get feedback, any kind of feedback from him on the whole process besides obviously the participation?
• 38:42
  You know, he, with the language skills that he had, he did just let me know, he's like, okay, stop dressing up as a doctor when you come over.
• 38:50
  And I was like, okay, no problem.
• 38:51
  um But he, I did talk to him that day after he got the blood draw and I was like, that was awesome.
• 38:57
  Like, you did such a great job.
• 38:58
  How was it?
• 38:59
  And he was like, no problem.
• 39:00
  Like I did it.
• 39:01
  And I was like, okay, that's awesome.
• 39:04
  So yeah, it seemed like he knew um how great of a job that he did.
• 39:09
  um
• 39:11
  I don't know if he could truly compare the amount of stress that he was in compared to prior to CET to then when he actually went.
• 39:19
  But he, yeah, he did a phenomenal job and he put in all the work.
• 39:23
  So really it's applause to him for doing each step and really meeting each criteria and getting to that point.
• 39:29
  So.
• 39:30
  Hmm.
• 39:30
  Hmm.
• 39:34
  And.
• 39:38
  Do you have a sense of, I don't think a lot of this is really important.
• 39:42
  I think sometimes we worry too much about root causes of some of these problems and what initially triggered an individual who's been engaging in SIB for 40 years to start hanging
• 39:56
  his head and how important is that really now to sort of the treatment?
• 40:02
  But did you have an idea of sort of why he had such a massive fear of needles?
• 40:08
  Did he actually get a needle once and like unsuccessfully?
• 40:13
  Or was it just like what sort of you think kind of created this fear in the first place for him?
• 40:21
  You know, I think it's an interesting question.
• 40:23
  I don't actually have an answer.
• 40:25
  I don't know where this came from or even how long it really had been occurring for.
• 40:30
  um
• 40:31
  But really when we took this approach and when we were in the assessment piece of CET, we were really looking at what's currently maintaining the behaviour.
• 40:40
  Like what contingencies are in place right now that he continues to try and create distance or escape from these things.
• 40:48
  And that really was what guided our intervention.
• 40:52
  So something different may have been the cause or the initial start of this, but what was most helpful was the current contingencies that
• 41:02
  maintaining the behaviour.
• 41:04
  Because it makes me wonder, and maybe this is a separate question or a separate sort of procedure uh about prevention here and sort of early intervention and how, because I think
• 41:21
  a lot of people.
• 41:22
  kids, adults are are afraid of needles.
• 41:28
  You were mentioning getting your blood drawn and you even being afraid.
• 41:31
  I remember I went to give blood once to the Red Cross and I actually blacked out and had to have the orange juice and the cookie.
• 41:43
  before I pulled my sleeve up, just from walking in and watching everybody's blood coming out of their bodies into these bags was too much for me and I lost it.
• 41:52
  And it took me a long time to go back and try again.
• 41:57
  And so...
• 41:59
  So it's a thing for a lot of people.
• 42:02
  so have you thought about that, about sort of uh how maybe exposure therapy might be a good tool in early intervention to prep people for their very first experiences with these
• 42:15
  medical procedures and other scary procedures?
• 42:19
  Yeah, our research group has actually talked about this a little bit.
• 42:23
  um And one of our members, Andrew Miller, has actually done this um and has been successful in kind of preparing someone to have injections in their leg.
• 42:35
  And from the beginning, kind of taught the reinforcement system and all the movements in the interconnected chain prior to the first actual injection.
• 42:44
  And then it went so smooth.
• 42:46
  And so I think some of the prevention
• 42:49
  work, who knows?
• 42:50
  Maybe that person would have been totally fine with the injections anyway without all of it, but I think that it was a really fun process to get to watch and hear him explain the
• 43:02
  progress throughout it and get to see it kind of step by step.
• 43:05
  So I definitely think that there is a possibility here, but I do think a lot of our focus has been if we're already seeing those distress indicating behaviors, how can we support
• 43:15
  in that area?
• 43:17
  yeah, because it makes me think about, uh I've got Katie Gibson coming on.
• 43:21
  She's going to be talking a lot more about medical procedures and especially about how she's trained medical professionals, nurses and doctors and the like to do CET themselves
• 43:32
  with folks.
• 43:34
  And again, I wonder.
• 43:37
  you know, and again, off track a little bit here.
• 43:40
  But I wonder sort of, know, even hypothetically, philosophically, you know, what creates these initial fears in the first place?
• 43:49
  I mean, in the whole scheme of things, a needle doesn't hurt that much.
• 43:53
  um You know, it's, you know, there's a lot more painful experiences children go through in their lives and don't run away from kids wipe out on their bikes all the time and get back
• 44:02
  on the bikes.
• 44:03
  And it probably hurts a lot more than a little pinprick.
• 44:06
  And so
• 44:07
  I wonder about sort of those early, that early kind of verbal behaviour that they're exposed to around needles and sort of the, you don't worry, close your eyes.
• 44:19
  This will be quick, you know, sort of a lot of these sort of uh preparing people for the possibility of a scary situation in their very first exposure, we kind of set them up for
• 44:31
  failure.
• 44:33
  Yeah, I agree and I share your interest.
• 44:37
  I think it'd be very interesting to understand really where a lot of these things are coming from and really what is the moment and the variables that are all contributing to
• 44:47
  what starts some of these things and why one person may experience the same situation and not be affected by it.
• 44:54
  And while someone else may then start to engage in all these fearful behaviors following that event.
• 44:59
  um
• 45:01
  I it's so interesting.
• 45:02
  wish I had the answers for you, but I think it's still areas we're investigating.
• 45:07
  Absolutely.
• 45:08
  again, a lovely example, the blood draw and uh the nail clipping was another one that again, I think.
• 45:20
  without kind of getting into the whole weeds of it, just for listeners that may not have heard the whole story.
• 45:27
  How long did that one take as well?
• 45:29
  How long did it take to go from a kid whose mother was clipping his toenails while he was asleep to him clipping his own toenails and for the sheer social reinforcement of proud
• 45:43
  parents?
• 45:44
  How long did that whole procedure take to happen?
• 45:49
  Wow.
• 45:50
  Yeah, yeah.
• 45:51
  And so again, that's just that that stuff's just a little mind blowing.
• 45:57
  And and so I'd like to talk a little bit about because I think a lot of folks are going to be keen to try this stuff.
• 46:05
  And uh
• 46:06
  And right now, think access to, I'm hoping the series will provide some of that as well, but right now access to the constructional approach is limited.
• 46:15
  There's not a lot of folks that are out there that have specialized in this.
• 46:21
  The conversations seem to be happening primarily at a couple universities in the States.
• 46:26
  I know there's some work being done in Australia as well.
• 46:30
  But generally speaking, Joe's lab is sort of...
• 46:35
  the folks that are doing this sort of thing.
• 46:38
  when we often hear about sort of, and I realize it's apples and oranges here, but when you often hear about other interventions, something that's gained a lot of traction lately is
• 46:48
  of course, Hanley, SBT, all that kind of thing.
• 46:52
  There's like seven levels of certification one might need to go through to do well at that.
• 46:58
  We talk about, you know.
• 47:00
  sexuality and requiring, you ah know, folks with sort of multi-level certifications to provide consultation on these cases.
• 47:09
  uh Can we talk a little bit about...
• 47:14
  uh
• 47:18
  First off, I'd like to talk a little bit about you and your initial experiences with this.
• 47:25
  That nail clipping example, and when we talked before we hit the record button, you said this was the first time you had ever done this.
• 47:33
  And so tell me a little bit about what sort of training preparation you had before implementing that and.
• 47:42
  m
• 47:45
  It only took an hour, so there obviously wasn't a lot of mentoring and feedback during the procedure because it was just one and done.
• 47:52
  Yeah, my experience to this prior was I had seen a talk given by Awab and Andrew at ABAI where they presented on a case of CET.
• 48:06
  And so I got to see this great model of what this procedure looked like and the outcomes that this procedure was getting.
• 48:14
  And so that in and of itself was incredibly helpful.
• 48:19
  And then in addition to that, uh
• 48:21
  Dr.
• 48:22
  Joe Layng and Awab had also published an article on constructional exposure therapy, really breaking down the key pieces of it.
• 48:29
  And so between reading that and seeing this model and having a few conversations with Awab I basically took all of that.
• 48:39
  and was presented with this opportunity where this mom had come to me because of this child's fear with nail clipping and I had known this learner for a while and so we
• 48:49
  discussed what this looks like.
• 48:52
  Mom was in agreement, we discussed it with him, he was in agreement and yeah we just did it that day and I think he taught me a lot about the procedure as we were going through
• 49:01
  it.
• 49:01
  um
• 49:03
  And I made some mistakes.
• 49:04
  I think that was highlighted in the talk you saw at the constructional conference.
• 49:09
  And those are all learning experiences, you know.
• 49:12
  I would do things differently now than what I did my very first time implementing it.
• 49:17
  But even with, you know, that small fidelity error, we still saw the great results that he had.
• 49:23
  So.
• 49:25
  So you watched the presentation, you read a paper, and you had a few chats with Awab and you were able to go out and implement this program.
• 49:36
  And so it seems like a fairly accessible uh method for folks.
• 49:44
  If a clinician listening wanted to start using CET tomorrow, they have a client that they've been struggling with some of these, you know,
• 49:55
  really sort medically necessary procedures and whatnot, where do they begin?
• 50:02
  Yeah, I think that's a great question.
• 50:05
  I also know a lot of members within the group are actively pushing to get more resources out there.
• 50:11
  There's a lot of articles that are in press right now going through a review.
• 50:14
  So I hope soon that there's going to be even more resources for people to access.
• 50:19
  um Additionally, there's two new books that are coming out that I think are going to be incredible resources.
• 50:25
  There's going to be a second version of the nonlinear contingency analysis book, which in general is just going to support people with the
• 50:32
  constructional approach.
• 50:34
  But then there's also another book of case studies that's going to be coming out with the NCA book and that is going to have a ton of examples across a variety of populations and
• 50:46
  skills of applying CET along with many many other things.
• 50:50
  And so um hopefully that's going to be out soon and will be another great resource for people.
• 50:57
  I would also say feel free to reach out.
• 50:58
  There's a lot of people in our group that are happy to have those same conversations that Awag was so generous with me in the beginning.
• 51:06
  And so we would be happy to keep chatting through these things.
• 51:09
  We're constantly learning more and trying to disseminate more.
• 51:12
  That's awesome.
• 51:13
  know, and Awab also shared, there's a Facebook group as well, that's available.
• 51:19
  That is an incredible resource also.
• 51:21
  There's that space for discussions and asking questions and being able to have those questions answered by other people who are actively doing this work.
• 51:30
  And we also try to constantly put those resources that are just coming out on that Facebook group.
• 51:35
  So that's another easy way to be like, here's the next thing that's come out and I can access it and take a look.
• 51:43
  Really cool.
• 51:46
  And so what's, what's, there's one other piece and I'm going to have to hit pause and edit because I'm mumbling and stumbling on what I was going to ask you.
• 51:58
  Um, yeah, yeah, yeah.
• 51:59
  So I think, think another thing you said that resonated for me.
• 52:05
  your very first time running it.
• 52:08
  That the young man taught you a lot during the procedure.
• 52:14
  And I think.
• 52:16
  I wouldn't mind having you elaborate a bit on that because that was something that Awab talked a bit about too in that the...
• 52:23
  oh
• 52:29
  And I'm hoping to get more into this with some of the future guests that we're going to have on.
• 52:34
  But this idea of assent and the withdrawing of assent and how we can take that assent withdrawal as a learning experience.
• 52:47
  And we have an opportunity to learn directly from our client each time they withdraw.
• 52:54
  And so I wonder if you could talk a little bit about kind of
• 52:57
  that concept and how that applied with this fellow.
• 53:00
  Yeah, so I think in the moment I learned a lot from him and then on the greater scheme of things I also learned a lot from him.
• 53:11
  So when we're talking about what he was agreeable to and what he was not agreeable to, that was so informative for me because as we chose to progress throughout the shaping
• 53:22
  procedure, um I would learn, okay, this big of a jump is okay.
• 53:28
  We can do...
• 53:29
  this big of a step.
• 53:31
  And we started from just presenting the nail clippers all the way across the room, showing it to him, having him look at it, and then putting them away.
• 53:38
  And we would slowly move closer and closer until we were actually at the same table with him sitting down and...
• 53:45
  We would have him present his hand.
• 53:47
  We would bring the nail clippers up to his hand and we'd give him a break.
• 53:50
  And it was once we got to the point where we were going to actually cut his nail, um he began to show all these different signs of distress.
• 54:00
  And being my first time, I had not seen that before because he was very calm through all the previous steps up to this point.
• 54:08
  Mm-hmm.
• 54:08
  And so I kind of tried to push him through it when, you know, if we're looking at the actual procedures of CET, we wouldn't do that.
• 54:16
  We would provide that escape and distance contingent on that first sign of distress, change our procedure a little bit and try again.
• 54:23
  um And so it really was in that moment where now I saw all this distress happening because of something that I was doing as the implementer by not giving that removal, by not
• 54:34
  honoring that withdrawal of assent And that really taught me how
• 54:38
  important that is to one honor that and one learn from that to make these changes because we did we we made those changes and he was able to get right back onto those shaping steps
• 54:53
  and again within that hour was able to transfer from me to mom and mom cut all 10 of his fingernails but i think that that also taught me a lot in general of
• 55:05
  It's actually faster and we progress through the procedure more when I don't have to uh push someone to escalate to such a point where now I have to support them and calming down
• 55:17
  and coming back to baseline levels of responding.
• 55:21
  um
• 55:22
  I can just honor it before it ever gets to that point, give a quick break like we've been doing anyway, and then jump right back into the learning context.
• 55:30
  And I think that was like a big eye opener to me.
• 55:32
  And I was like, this is, this is why we, you know, honor these things.
• 55:36
  It's respectful to him.
• 55:38
  It's compassionate to him.
• 55:39
  I don't have to be this person that's causing all this distress, but also it's not only just more compassionate, but he's able to now learn and get back to the learning
• 55:49
  environment a lot quicker than what we would have.
• 55:52
  done if we just kept pushing through it.
• 55:54
  So yeah, he taught me a lot of lessons and um you know I'm very grateful because he's just honestly such a great person um but would give feedback to you know this is how I felt
• 56:07
  when I was going through this procedure, this is how I felt after the procedure and he was able to give a lot of that feedback which was incredibly helpful.
• 56:16
  Yeah, yeah.
• 56:17
  And I'm wondering also just, I said we weren't going to dive too much into this case, but there was one other section of the case that I, maybe I just got distracted during the
• 56:27
  presentation, but I think you quite quickly got to the point where mum could easily clip all of his nails and he was doing great and he was loving that.
• 56:39
  Tell me about what the shift looked like from mum clipping his nails to him clipping his nails.
• 56:45
  Yeah, so that did happen on a different day.
• 56:47
  are originally our outset from the outset.
• 56:51
  We had determined, OK, the behaviour, the absence of which is the problem is allowing someone to cut your nails.
• 56:57
  And so we were able to achieve that in that hour and that maintained.
• 57:01
  And, you know, each time I'd come check in, Mom continued to cut his nails.
• 57:05
  But then we had decided with him and with the family that it would actually be best to let him do it.
• 57:12
  He had all the prerequisite skills, the fine motor skills.
• 57:15
  to do this and this would allow him to cut it on his own pace in his own style keep it at the length he wanted it would just give him a lot more choices and control over the
• 57:25
  situation and so we did another short round of CET I want to say it was 25 minutes but don't quote me on that I have to look again uh
• 57:37
  And yeah, we were able to get him to the point where he was cutting both hands.
• 57:42
  And it was really special because he was so excited for it.
• 57:45
  Dad came home early from work just to get to see him finish his other hand because he wanted to show him.
• 57:50
  So.
• 57:51
  um
• 57:52
  Yeah, it was a very quick process to get from the point where mom was doing it to where he was doing it.
• 57:58
  And that quickness really comes from the skillset he came in with.
• 58:02
  Sometimes if you have to teach some of those skills involved in that repertoire, it might take a little bit longer.
• 58:09
  And I think that that's okay.
• 58:11
  And so what were, you don't have to tell me all of them, but what were those steps?
• 58:16
  So briefly, did it start with mom clipping his nails?
• 58:21
  Or what was sort of, in the second day, what was the, yeah, yeah.
• 58:26
  Yeah, so the second session, was um not mom involved.
• 58:32
  So this was just him and I and having the nail clippers on the table.
• 58:35
  And I want to say we started with just having him with both hands pick up the nail clippers and then he'd put them back down.
• 58:42
  And that was like step one.
• 58:43
  And the next step was pick up the nail clippers and touch them to your own nail and put them back down.
• 58:48
  And then we would have him for the next step, put his nail inside the nail clippers.
• 58:53
  but not necessarily clip them.
• 58:55
  And we basically just worked our way up to actually getting like one clip and then we would do two clips on a finger and then we would do three clips and we just got it until
• 59:04
  he was...
• 59:05
  doing it no problem and he was just, yep, I got this.
• 59:08
  Okay, let's go take a break, you know.
• 59:10
  So uh what was nice is we saw in both of those cases that switch over effect where in the beginning his responding really was maintained by that distance and the removal of the
• 59:22
  nail clippers.
• 59:23
  But by the end of it, he was just clipping his nails because of the positive social reinforcement he was getting from both of his parents and how proud they were of him.
• 59:31
  And he was just so excited to get to show his fingers off to them.
• 59:35
  Yeah, that's amazing.
• 59:37
  And so it sounds like the steps themselves weren't much different than from the previous day.
• 59:42
  Just now it's his hand instead of mom's hand, um sort of doing all those things.
• 59:47
  And I think that other piece about the social reinforcement, I think, is big.
• 59:52
  And I think has come up in some of the other conversations that I've had with folks in that.
• 1:00:01
  And maybe we don't even, maybe something we don't realize that these folks have all had this fear for so long and the act of overcoming that fear is pretty reinforcing in of
• 1:00:15
  itself as well.
• 1:00:16
  Is that something we're seeing and just hearing and sort of the social attention associated with it is way more powerful than kind of anything else.
• 1:00:27
  Yeah, I think what we've seen and what other implementers have seen as they've gone through this process is once that negative reinforcement contingency is addressed through
• 1:00:40
  a constructional exposure therapy, then the program specific consequences are allowed to take their effect.
• 1:00:46
  So the things that now he's able to do and get his parents to be so proud of him, that can actually have an effect on his behaviour because uh the the distance and escape is no
• 1:00:58
  longer motivating for him.
• 1:01:00
  He does.
• 1:01:00
  He's not experiencing those same uh responses to that nail clipper anymore.
• 1:01:06
  And I think we see that across a lot of cases, even in the blood draw,
• 1:01:10
  case, we were seeing it to where he would come over and he would sit down for a long period of time just so he could have a back and forth conversation with the team that was
• 1:01:20
  practicing with him, not necessarily to get rid of the medical stimuli.
• 1:01:25
  And so once the escape is depotentiated, it allows for all these other positive reinforcement contingencies to take effect.
• 1:01:34
  And I think we've seen that pretty consistently across a wide variety of our cases.
• 1:01:39
  That's awesome.
• 1:01:41
  You're only like first year into this stuff.
• 1:01:44
  So tell me about some of the other projects you're working on and uh what the next year or so is going to hold for you and your learning.
• 1:01:59
  Ben, there's a lot coming.
• 1:02:01
  No, I think there's a lot more coming with constructional exposure therapy.
• 1:02:06
  We're constantly trying to really refine the procedure, identify like what are the most effective and efficient ways to provide this in a way that's gonna have the most impact
• 1:02:18
  for the person that we're doing.
• 1:02:19
  And I think it just changes context to context.
• 1:02:22
  So I do hope that we will continue to work on those things and have more out.
• 1:02:27
  We're also doing a few studies on
• 1:02:29
  genuine choice, which is something that Israel Golddiamond talked about.
• 1:02:34
  And I think that just ties back to genuine assent and being able to have these alternatives and what is really required for something to be a genuine alternative.
• 1:02:45
  um And I think that I'm, again, from the beginning, I've been so interested in that area.
• 1:02:50
  And so I'm just hoping to get some more empirical data on the variables that are involved and what is needed in these contexts to reduce coercion and
• 1:02:59
  um what that looks like.
• 1:03:02
  And so yeah, I hope that maybe we'll talk about those one day too.
• 1:03:07
  I look forward to it.
• 1:03:08
  Danielle, this was really cool.
• 1:03:09
  I loved learning about CET with you and love seeing your passion for this work and stoked to see what's coming up.
• 1:03:17
  Thanks for coming on.
• 1:03:18
  yeah, thank you so much for the invite.
• 1:03:20
  It was an honor to get to chat with you,
• 1:03:22
  Right on.