Just a Little Bit Better

Ten years after Braulio Montalvo succeeded Salvador Minuchin at the reins of the Philadelphia Child Guidance Clinic, an interviewer asked him what the biggest difference was in his impressions of family therapy from the early days. He stated that he learned to expect less, that families didn't change as radically as what was hoped for when family therapy was nascent. Yet, what became clear to me after practicing family therapy for two decades, was that small changes in families were often perceived by family members as big.

As a couples and family therapist, I learned to ask a simple question. What is the smallest change that needs to happen in order for you to know that things are getting better?

When people were able to focus on making small changes, they felt better. Change did not have to be daunting, and they could see their accomplishments and feel good about their success.

As behavior analysts, we know this well. We are taught to shape behavior by breaking down complex behavior chains into their smallest parts, and we teach "successive approximations" until the complex behavior becomes seamless.

Can we apply our own methods to ourselves? What if we told ourselves, "what is the smallest change I can make in order to know things are getting better?" Would we choose not to focus on losing 20 pounds, but instead on 2? Would we choose to finally pick up the musical instrument that sits dormant, and practice for just five minutes a day? Would we choose to write one page of our dissertation or that article we have been intending to tackle, instead of focusing on completing the entire project?

I am a sixties (that's 1960's, not 1860's) musical fanatic. I can't help but think of Peter Noone singing the chorus of one of Herman's Hermits great songs: Now ain't that just a little bit better?

Happy Kaizen New Year!

Those of you who have recently been meandering around the hallowed halls of Pacific Child and Family Associates have heard me muttering the word "kaizen" repeatedly under my breath. This is my new mantra. I have been trying to implement this American-born and Japanese-bred management style at Pacific Child, in true kaizen style, little by little over the last couple of months. Things are going great here, and I do believe this approach is a very cozy bedfellow for those of us who call ourselves behavior analysts. It is a method that encourages personal initiative. It is interactive and flexible, creating cycles of creative progress which ultimately lead onward and upward.

So, in the next few blogs, I intend to clue you in on the principles of kaizen and how they apply to what we do.

There are several facets of the kaizen approach, some big ones and some not so big ones. One key element is the focus on making small, measurable change, as opposed to large, radical shifts. Sounds like ABA, yes? We take our baseline, assess the problem, make a plan, measure the outcome, and memorialize the results if they are positive. It is the classic A-B design.

But in this entry, I want to focus on another piece of kaizen philosophy. That is the piece having to do with the importance of taking care of oneself. It is about working hard at what we do, but not so hard that we allow ourselves to get burned out.
In this holiday season let’s pause and consider how self-care gives us more energy to care for others as well. Self care doesn’t mean self-indulgence, or being self-centered. And it’s much more than finally taking that long, slow bath or treating yourself to a massage. Nurturing oneself can also mean embracing the kaizen principle of ‘personal discipline’ as a daily practice. That type of self-care helps us reduce from our lives those things which waste time, energy, space and resources. We find we have more time and more energy.
It’s not about expecting more from oneself than is reasonable. Rather, recognizing that the kaizen elements of effort and quality and can be applied to our own lives as well as our work. Underlying it all is the willingness to change.

Research has shown that the majority of New Year’s resolutions are broken very quickly. The one-shot, sudden approach, no matter how well-intentioned, can fail us. I’m going to look toward 2011 as the beginning of a fresh personal philosophy, inspired by the kaizen method of sustained change which is aimed at gradual improvement in a humane, people-oriented way. I hope to take better care of myself and in so doing take better care of our employees and our clients. Happy New Year.

Rising Stars

Just some words of congratulations on some of Pacific Child's rising stars. Marta Marquez and Hilary Zeller are our newest BCBAs! Congratulations on leaping the final hurdle. Also, I want to congratulate LaDonna Haltom, one of our senior therapists in the Southern California office, for being promoted to a supervisor position. Also, I want to welcome aboard two new supervisors. A warm welcome goes to Laura Simpson, our newest supervisor in the East Bay office, and Andria Hernandez, our newest supervisor in the Inland Empire office. We welcome your commitment and passion and your dedication to providing the highest quality ABA services to our clients. Congratulations to you all, and welcome aboard.

"Go East!"

“Go West, Young Man, Go West!” were the famous words written by Horace Greeley in support of Manifest Destiny. For Pacific Child, this is a difficult calling, because we have been born and bred in the west. So for Pacific Child, our most recent calling is to “Go East!”
I am thrilled to announce that Pacific Child is opening its first office in the Midwest, which to us in California is really the East. Deb Ewen Miller, who has shepherded our Eureka, California office so brilliantly in the last several years, will be running our first office in Duluth, Minnesota. We hope to serve the entire Minnesota area out of this office.
As we embark on our Easterly expansion, I want to thank Deb Miller for her extraordinary work among the redwoods of Northern California. We are truly blessed to have her continue her work with PCFA, and brave the bitter winters, in Minnesota.

Lifelong Learning

There was a phrase I heard constantly throughout my childhood. In the Bronx accent I usually heard it, it sounded like this: “You live and you loyn.” Translation: You live and you learn. It was most often uttered as a way of comforting someone when something happened that wasn’t quite right, kind of like, well, you won’t make that mistake again and it will be alright.

But, as is typical with phrases that hang around for a lifetime, there was a lot more to it than that. Do we, in fact, “live and learn”?

In “The Once and Future King,” T.H. White writes (through the character of Merlyn):

The best thing for being sad… is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins,… you may see the world around you devastated by evil lunatics, or know your honor trampled in the sewers of baser minds. There is only one thing for it then—to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting. Learning is the thing for you.

For many of us, the product of our education system in the U.S. is to see learning as a chore. It is something we have to do to go from here to there, like an uncomfortable bus ride over pot-holed streets. But in Merlyn’s comforting words learning takes a different form. It is a kind of therapy, a comfort and a solace. It is to some degree a place away from the hectic world of business and rumor, but it is also a powerful tool with which to engage life. Perhaps most importantly it is an antidote to “fear and distrust.” Learning, the pursuit of the truth, guided by a moral compass, leads to compassionate understanding and is a powerful weapon against those “evil lunatics” who, in reality, fail to understand or see the deeper truths.

A Great Loss

O. Ivar Lovaas died just over a week ago at a hospital in Lancaster. He was 83 years old. I did not know him personally, although I spoke with him on a couple of occasions and attended a lecture of his at Cal-ABA on self-stimulatory behavior. To say that Lovaas was an icon is an understatement. Although he was not the originator of the methods that eventually became so associated with him that for many years they were called “Lovaas therapy,” his contributions as a researcher and tireless promoter were huge.
In reality, the methods he used to treat children with autism and others were developed by his mentors at the University of Washington—Don Baer, Todd Risley, Montrose Wolf, and others—methods that eventually came to be called applied behavior analysis. Lovaas was a graduate student at the University of Washington who had been trained in classical psychoanalytic methods, and although he became perhaps the most well-known advocate for behavioral methods for children with autism, he never swayed completely from his psychoanalytic roots. In fact he was probably the only behavioral researcher who gave Rorschach tests to his subjects.
Lovaas was a controversial figure, revered by many and reviled by many others. In his early work, he occasionally used aversive procedures, which he defended adamantly although he eventually abandoned them in favor of non-aversive procedures. He claimed for some time that the only way to achieve the formidable results he achieved was to be trained only by him or those authorized by him, thereby giving a proprietary flair to his methods. In true scientific fashion, many academicians looked askance at anything proprietary, capitalism and science being the awkward bedfellows they can sometimes be.
Those who knew him and were close to him have told me that he was often sweet and charming, but definitely genuine. You knew where you stood with him. In my view, his responses to those who criticized him occasionally lacked sensitivity; he did joke at times that his Norwegian farmer roots led him to say things simply and directly. There can be no doubt that without his contributions, many thousands of children would not have received the help they needed.
In the last few years, he had been diagnosed with Alzheimer’s, and he did not lecture or appear in large public forums. He eventually died of an infection following hip surgery. He was a giant and we will miss him. Most importantly, those of us in the field of helping children with autism owe him a deep debt of gratitude.

Great Perseverance

If we are facing in the right direction, all we have to do is keep on walking. - Buddhist Saying

In my first full-time job as a psychologist, I was lucky enough to have two children diagnosed with autism in my caseload. One of them had participated in Lovaas’ 1987 landmark study, and the other was the subject of a book about a play therapy technique. Both of these children improved dramatically, so much so that the medical director and child psychiatrist at the agency said to me that he thought these children were misdiagnosed. The reason? “They couldn’t have had autism because they got better.”
Prior to the ABA “revolution”, professionals dismissed children with autism as incapable of learning, of “mentally retarded,” because those simple things other children could learn to do quickly, either through simple imitation or quick demonstration, children with autism could not. But those of us who work in this profession know that this is not the case; that skills which may take a “typical” child one or two trials to learn, may take the child with autism one or two thousand trials. Yet they do learn.
The difference between a child with autism growing up to be an adult with autism and a child with autism who may grow up nearly indistinguishable from his or her peers can be boiled down practically to one thing: perseverance. It is the great perseverance of those around them who have the patience to work hour after hour on teaching simple skills. It is the perseverance of the parents who themselves intervene and struggle, minute-by-minute, with the required caretaking and emotional stamina. And ultimately, it is the perseverance of the child him or herself, who works diligently hour after hour, through much frustration in order to “rewire” a neurological system that is wreaking havoc with his or her development.
The “magic” that is ABA is, of course, no magic at all. Those of us who ply that trade have often wondered why it took so long for ABA pioneers to “discover” that simply taking skills and breaking them up into their component parts and training through repetition, prompting and reinforcement could allow our children to break free of the bonds of silence and withdrawal.
Perhaps it is the loneliness of non-functioning in the mainstream world that spurs the perseverance of the child. Or perhaps it is the love and devotion of parents and caregivers, who themselves persevere. But this determination to keep going, to keep trying which method works for which individual and to repeat and repeat until there is progress, turns into a reciprocal experience. We persevere so the child perseveres. When the child perseveres it inspires us to do likewise.
Each child with autism presents a unique set of challenges. But one thing that is shared among most is the sense that change occurs ever so slowly. It is easy to give up in the face of the pain. It is a similar challenge each of us faces when confronted with our own devastations, such as the loss of a loved one, our own diagnosis of a life-threatening illness, or a traumatic life upheaval. At times, the devastation can be so great that we feel as though we are losing our breath.
There are many clichés about what comes next. But the bottom line is that we must take one breath at a time, walk one step at a time, face the right direction and keep moving. We must not lose our great faith, we must hold on to our great doubt as our partner, and above all, we must persevere.

Great Doubt

My last blog entry mentioned the three tenets of a “successful” Buddhist practice: great faith, great doubt and great perseverance of effort. I wrote about great faith, and how it applies to the everyday lives of those working with children with autism. Both faith and perseverance are relatively self-evident ingredients. Great doubt is perhaps the least self-evident and yet equally important.
In the Buddhist tradition doubt is required in order to challenge and eventually overcome the tendency to “understand” something superficially. So many concepts can be grasped at so many different levels, and the more superficial our understanding the less likely we are to succeed.
In autism, parents are exceptionally vulnerable to the unproven, snake oil treatments that are marketed their way endlessly. Whether it is the promise of secretin infusions, chelating heavy metals, megavitamin treatments, or the more subtle hopes of sensory integration, play therapy, or other unproven methods, parents are lured to do things for their children that range from the directly harmful to the indirectly dangerous misappropriation of valuable time, money and energy that could be spent on things that actually do help. In these situations, it is great doubt that steers parents towards making the right decisions.
As therapists and supervisors, we too can be lured in by so-called treatment advances that have little or no research evidence, but that can tempt us to divert our valuable time and energy from proven, effective methods. Great doubt is the gift of skepticism that leads us to greater prudence in choosing our treatment methodologies and skillfully adapting them to the needs of the individual child.
Great doubt as our companion makes professionals better students. It leads us to always question authority, to refuse to take someone’s word that one action is better than another, to refrain from sycophantism, and to let intellectual honesty and scientific rigor underpin our efforts to help.
Some see faith as the absence of doubt and doubt as the absence of faith. In the Buddhist tradition the two co-exist; they do not negate each other but can occupy the same space. Sensei Sevan Ross, director of the Chicago Zen Center has described faith and doubt as “two ends of a spiritual walking stick.” We grip the ‘faith’ end and poke ahead with the ‘doubt’ end. It is our determination (Great Perseverence, which I will discuss in my next blog entry) that allows us to pick up the stick and to continue on our journey.
It is the acknowledgement of doubt that makes faith in Buddhism mean something different than faith as religion. It is more a ‘practice’ than a religion or ideology. Likewise, dealing with autism should be a practice that we engage in on a day to day basis, not a religion where we become sure that we have found a certain method that becomes the one right path. We need faith to deal with our fear. But healthy doubt can accompany faith. In our mindful daily practice, we as professionals should work together with parents and children in such a way that neither rote approaches nor the belief in the certainty of our methods should limit us.

Great Faith

I am and have always have been fear-based. Among the long list of my weaknesses, this is perhaps at the top. I lose sleep as a result of fear, it drives my anxiety, and it is the sweetest nectar for the demons that get between me and that elusive state of inner calm. It is my constant, unrelenting companion, and it gnaws at my soul.

Traditional psychological wisdom holds that the antidote to fear is courage. Courage is holding the fear as your guidepost while you take action toward resolving the thing that is feared. While courage is certainly the most direct medicine, it is often difficult for me to find it on the shelf. There is another antidote that I have been trying to ingest that some suggest might work just as well. That antidote is faith.

In the Zen Buddhist tradition it is often held that there are three elements needed to make spiritual progress: great faith, great doubt and great perseverance. In the world of autism treatment, we face the deep need for all of these. We need faith to overcome the fears that surround us: the fear that our children won’t learn to speak or have friends, that our interventions won’t work, that we won’t be as good as we can be, that we won’t be able to get that report done on time, that our supervisors or the parents with whom we work won’t like us, that the economy will threaten our jobs, and on and on.

Many religious folks will tell you that the problem with the word “faith” is that it is a noun. As such, it is something you either have or don’t have; it is something you can somehow possess. This is problematic because faith is really something you do, not something you have. (Arguably it should be a verb; harden the “th” sound as in “tithe” and pronounce it as though it were spelled “fathe.”) One does not “have faith” but instead one actively “fathes”. To fathe is to actively believe that one can do or accomplish or have or be or overcome the thing that is feared. Whatever obstacles fear engenders “faithing” can overcome.

Faith often teases truth to the point where those who are strongly wedded to truth and its kissing cousin reality become dismissive. When I feel most troubled, I cannot bring myself to believe things that I wished were true but that I have no evidence to believe are in fact true. I can, however, make “soft plans” coupled with the belief that somehow, either operating within or outside of the box, I can get to the other side of whatever I fear.

Parents of children with autism “fathe” their way into seeing their children as gifts, celebrating each small victory of learning along the way. PCFA staff “fathe” their way into finishing their reports, confronting their supervisors, trying new interventions, facing crowded freeways, and instilling confidence in their supervisees.

Faith, I believe, must become as natural as the breath. If absent, it requires intention to revive it, but it should become our constant companion in order to combat the fears that plague us. So when the fear rises up within us, we “breathe” the belief that we can do the thing that is feared, and this faith transforms the energy used by fear to the energy required to take action.

It is always this brief suspension of “realistic” thinking that allows us to take the leap to become just a little more than we are. It allows us to have the courage to love better, to confront those who hurt us, to receive love and the other gifts those in our lives try to give us, and to see the world as filled with potential and awe. Faith is a true antidote to fear; it can still the demons inside us and guide us toward a sense of peace.

The Art of Science

In younger days, whenever a group of pretentious young adults got together for a gathering, it wasn’t long before someone brought up the question: “What is art?” The idea was to try to say something intelligent without sounding too silly, nearly always an impossible task. Eventually someone would say something about art similar to what Supreme Court Justice Potter Stewart said about pornography: that he couldn’t quite explain it, but “I know it when I see it.”
I have taught now for several years at UCLA School of Medicine. Initially the course I tutored was in the first year of medical school, and occasionally I would ask the students whether they thought medicine was a science or an art. Typically in the first year nearly all the students said it was a science. In the second year, however, the students were split more evenly down the middle. I have often wondered where the numbers would be by the fourth year. Real life, I suppose, can transform that which appears at first to follow the linear rules of scientific inquiry into the more mystical realm of art.
It has been said that good art awakens something in us, and becomes the abode of that which we might call “spirit.” Defining “spirit” of course is another party topic, one more likely to be heard these days than the question of defining art. For the moment, let us agree that spirit refers to some sort of essential life-force. It is that force that animates us, drives us to feel alive.
Behavior analysts are trained to believe that a defining characteristic of their profession is that it is a science. It follows logical rules, and decisions are based on data, not intuition or guesswork. The former of course are the domain of science, where the latter tends to reside in the realm of spirit. But I would suggest the opposite: watch a behaviorist at work. The truly good ones are artists. Their work awakens something inside of us, makes us feel alive. Their interactions are like impromptu dances, reacting gracefully and seamlessly to the client’s behavior. The behavior analyst as artist spontaneously creates something beyond the logic of science as she taps into her repertoire and responds with a deep awareness of the child’s needs, wishes, intentions and the environment within which the child interacts. As it is with most art, these results take years of study, years of “science”, years of clumsy, “bad art” to build on.
As the whole is always more than the sum of its parts, the behavior analyst creates something beyond the mere piecing together of the data. She uses those tools as a painter might learn how to mix colors, or which paints or brushes creates a desired effect. But the end result is the creation of something larger than the technical methods could do on their own. A child’s spontaneous smile, a laugh at just the right moment, the uttering of the first meaningful words, the twinkling in a child’s eyes as he discovers something new is an awakening of the child’s spirit. It is an awakening that comes often as the partial result of the creative efforts of the behavior analyst, the artistry and dedication, the creative and yes, even intuitive, dance between the spirit of the behavior analyst and the spirit of the client.

Invisible Rubrics

I have always loved my work, and have said that if ever the negatives outweigh the positives then it is time to reconsider my work life. At a recent supervisor meeting, I asked our supervisors for suggestions on how to make their lives at Pacific Child less burdensome. I wanted to know what they loved about their jobs and what they wanted to see different. Of course it was nice to hear about the positives, but I was concerned that people weren’t feeling safe to talk about the negatives. One supervisor used a phrase that I loved. She stated that she was afraid of the “invisible rubric,” and what I believe she meant was that she didn’t know exactly how she was being evaluated, and therefore carried around a lot of anxiety that what she was doing wasn’t what we, her supervisors, were evaluating her on.
It is always the unknown that frightens us the most, the monster hiding in the closet. And perhaps that is the greatest source of pain that the parents of our children with autism feel as well. The word “autism” originally meant “self-focused,” and focusing on oneself also meant shutting out the rest of the world. But if we truly believed there was no one hiding beneath the cloak of silent withdrawal we wouldn’t care much. It is that view, that there is someone hiding in the closet of our child’s mind that is so taunting. Who is this child? What is he thinking? What does he want? And what does he think of us?
In a strikingly parallel way, it is our children with autism who we believe lack the ability to determine (or even care) how others think of them (“theory of mind”). Our supervisors and staff work diligently to plant and nurture within our children the seeds of knowing and caring how others think about them, yet our supervisors themselves struggle to know what it is that they are being evaluated on, what it is that their supervisors think about them.
We are all evaluated by others, especially by those with whom we are close, continually. “Unconditional positive regard” was the watchword of the sixties, and it was as mythical as unicorns. So we struggle to know what it is that others expect of us so that we can choose freely whether or not we wish to jump through those hoops. But it is those invisible hoops that are the toughest, especially when the hoops are on fire.
So it behooves us all to make the invisible rubrics visible. But that is also a two-way street. When in doubt, ask those for whom we care what they want and expect from us, and let’s not be shy about making the deal go in both directions. Even those doing the supervision wonder and worry about how their supervisees are viewing them. Let us strive toward making our expectations clear, and let’s talk about it often and openly.