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Nearly 50 years later are we actually listening?
By: Abby Amacher, BCBA, LBA
My Dude, Just Make It to 18.
I've been practicing applied behavior analysis since 2008 and have been a BCBA since 2016. Over those years, I've spent thousands of hours working with children and teenagers, and one conversation came up repeatedly with my clients over the age of 12.
"My dude, just make it to 18. Then you can be as weird as you want."
Okay, that wasn't always the exact conversation. More often, it went something like this:
"When you're an adult, a lot of this stuff isn't going to matter. But right now, it matters to your parents, your teachers, and the other adults in your life. I understand that you don't care, but unfortunately, we still have to figure out how to navigate their expectations."
This explanation rarely went over particularly well with parents. But it often helped my teenage clients understand what the hell I was talking about. I wasn't necessarily telling them that the adults were right. I was helping them navigate a world in which other people had considerable influence over their daily lives.
One evening, a teenage client looked at me and announced, "I don't want to work with you anymore."
"Cool," I replied. "You don't get to decide that. But if you want to be done, let's go over your goals again."
And that's exactly what we did.
We reviewed the treatment plan, reconsidered our expectations, and revised several goals. Within six months, the client was discharged.
Goals met. And, more importantly, they agreed.
I had an established relationship with the family and remained in contact with them for years afterward. But the best part: they considered their own discharge a success.
Their objection gave us an opportunity to examine whether the things we were working toward were still meaningful to them. We didn't abandon treatment, but we changed its direction based on what they were telling me.
And it raises a question I've been thinking about throughout my career:
Who gets to decide what successful treatment actually looks like?
Wolf Was Asking This in 1978.
Nearly 50 years ago, Montrose Wolf published an article with arguably one of the greatest titles in the history of applied behavior analysis: Social Validity: The Case for Subjective Measurement or How Applied Behavior Analysis Is Finding Its Heart.
Wolf proposed three dimensions of social validity: the social significance of our goals, the social appropriateness of our procedures, and the social importance of our effects. But the part of his article that stood out to me wasn't the framework itself. It was an example from Achievement Place.
In a study examining teenagers' preferences for how adults interacted with them at Achievement Place, researchers asked the teenagers to evaluate adult behaviors. They also included behaviors suggested by the researchers themselves. The teenagers rated several of their own priorities highly, while many of the additional researcher-suggested behaviors received lower ratings.
The researchers had professional expertise, but they still needed to ask the teenagers what made those interactions meaningful.
As behavior analysts, we spend an enormous amount of time identifying target behaviors, collecting baseline data, measuring progress, and evaluating treatment outcomes. But all of that work depends on something we may not examine nearly enough: how we decided what was important to measure in the first place.
Are We Asking the Right Questions?
Professional judgment is an essential part of developing effective treatment. But being an expert in behavior analysis does not automatically make us an expert in someone else's life. When we assume our professional judgment accurately reflects the priorities of the people receiving services, we risk designing treatment around what we believe is important rather than what is meaningful to them.
And the consequences extend far beyond choosing the wrong goals.
We may spend months teaching a skill that has little relevance to the client's daily life. We may interpret resistance to treatment as a behavioral problem without considering whether the client values the outcome we're asking them to work toward. We may celebrate statistically significant improvements in behavior while overlooking the fact that the person receiving treatment doesn't consider their life any better.
Perhaps most concerning, we can collect perfectly accurate data and still arrive at the wrong conclusion. A graph can tell us whether a behavior changed. It cannot, by itself, tell us whether that change was worth pursuing.
This doesn't mean professional judgment is irrelevant, or that every treatment goal must reflect an individual's immediate preferences. Safety, communication, independence, and access to opportunities can involve skills that are difficult or uncomfortable to learn. But it does mean that our expertise should inform the conversation rather than replace it.
Before we decide how to measure success, we need to understand what success means to the person whose behavior we're measuring.
When Is a Disney Adult Just a Disney Adult?
For as long as I can remember, I was taught that we should encourage age-appropriate interests. I'm not particularly good at following directions, so I mostly ignored that advice throughout my career.
Because if I can buy a rose-gold Minnie Mouse backpack for $100 on a Disney cruise and happily use it without anyone saying boo to me, why can't a 40-year-old with a developmental disability watch cartoons and have a special interest in Barney?
Make that shit make sense.
Somewhere along the way, we've confused teaching age-appropriate skills with requiring age-appropriate interests. And those are two very different things.
Teaching someone to navigate adult relationships, manage their finances, advocate for themselves, or access their community can meaningfully increase their independence and quality of life.
If an adult enjoys Barney, has opportunities to participate in their community, maintains meaningful relationships, and is happy with their interests, what exactly are we trying to change? And for whose benefit?
We don't typically develop treatment plans for adults who collect Disney merchandise, attend comic conventions, build elaborate LEGO sets, or spend their weekends watching animated movies. We call those hobbies. We celebrate people's enthusiasm for them. Sometimes we even spend an absolutely unreasonable amount of money participating in them ourselves. (I have an entire collection of mini figures from blind boxes: they make me happy. I don’t care what you think).
Yet when someone with a developmental disability enjoys something we've collectively decided is intended for children, that same enthusiasm can become a treatment target.
This brings us right back to Wolf's question about the social significance of our goals.
Is the goal important because changing the behavior will improve the person's life? Or is it important because the behavior makes other people uncomfortable?
Those are not the same thing.
Socially Valid. According to Whom?
We have established that we should ask the people receiving our services what matters to them. Fantastic. Now what happens when we don't like their answers?
What happens when a teenager wants to stop attending therapy, their parents want them to continue, and their BCBA believes there are still important skills to address? Or when a teacher wants a student to sit quietly through an entire lesson, but the student would rather stand at their desk?
Whose priorities take precedence?
The reality is that we don't practice in a vacuum. Our clients exist within families, schools, workplaces, and communities, all of which have their own expectations. Caregivers have legitimate concerns about safety, independence, and the future. Teachers are responsible for entire classrooms. Clinicians bring specialized knowledge about behavior, learning, and skill development.
And the people receiving our services have their own priorities, preferences, and ideas about what makes their lives worth living.
These perspectives won't always align. And that comrades, is perfectly fine.
I don't think the answer is to disregard caregiver concerns or abandon our professional judgment whenever a client disagrees with us. There are plenty of circumstances in which we need to help someone develop skills they don't particularly enjoy learning. I don't especially enjoy paying my taxes, but that doesn't mean I can just skip my estimated tax payments.
However, there is a significant difference between helping someone develop a skill that increases their access to opportunities and requiring them to change simply because their behavior doesn't align with someone else's expectations.
Consider a teenager who doesn't want to participate in a particular social activity. Their parents want them to make friends. Their clinician has identified social engagement as a treatment goal. Their teachers believe increased peer interaction would be beneficial. Everyone agrees that social engagement is important.
Except the teenager, who would rather spend their lunch period reading a book.
Are we teaching social skills because this teenager wants friendships but doesn't know how to develop them? Are we helping them navigate interactions that are necessary to access something they value? Or are we attempting to make them appear more socially typical because the adults around them believe that's what a successful teenager should look like?
This is where I think we need to distinguish between asking for someone's opinion and allowing that opinion to influence our decisions.
We can administer social validity questionnaires, conduct caregiver interviews, document client preferences, and check every box on our assessments. But if the treatment plan looks exactly the same regardless of the answers, what was the point of asking?
And perhaps the most uncomfortable question of all is this:
What happens when a treatment goal is socially desirable to everyone except the person expected to achieve it?
If the only people who benefit from a behavior change are the people observing the behavior, we need to examine whether we're improving our client's quality of life or simply making their behavior more convenient for everyone else.
Content Note: Conversion Therapy
And this is where we need to talk about something considerably more uncomfortable than Disney adults and age-appropriate interests.
Wolf's 1978 article references research attempting to change gay men's sexual responses. It's an important albeit uncomfortable reminder what society considers desirable is not necessarily what is beneficial to the individual. (This part of behaviorism’s history cannot be erased, but it can be addressed. I will expand more thoroughly on this topic in a future article).
What happens when the priorities of the people around our clients are themselves harmful?
If we define social significance primarily through the expectations of the people around our clients, what happens when those expectations are discriminatory? What happens when an entire community agrees that a particular behavior should change, but the problem isn't the behavior? It's the community's response to it.
We cannot assume that a goal is ethical simply because it is socially desirable. Nor can we assume that obtaining approval from parents, caregivers, professionals, or community members establishes that an intervention is in the best interests of the person receiving it.
My morals are not your morals.
My personal beliefs about what constitutes a successful, fulfilling life should not automatically become the standard against which I measure yours or anyone else’s. As clinicians we bring our own cultural backgrounds, values, and experiences into every interaction. Recognizing those influences doesn't mean abandoning professional ethics. It means understanding the difference between our personal beliefs, the cultural expectations of the communities we serve, and our ethical responsibilities to our clients.
Social expectations change. Things that were once considered appropriate targets for behavioral intervention may later be recognized as expressions of identity, individuality, or harmless personal preference.
Our responsibility is not simply to help people conform to the expectations of the society they happen to live in. It's to examine whether the goals we're pursuing genuinely benefit the people we're serving.
And sometimes this is going to mean the C word.
(No, not that one).
CONFLICT.
Conflict isn’t necessarily a bad thing. Sometimes it means the person receiving services has a meaningful say in what happens to them.
Like when someone uses the “fuck off” button on an AAC device.
We say we want our clients to advocate for themselves, communicate their preferences, and establish boundaries. Are you still celebrating those skills when you’re being told to “fuck off?” Because I am.
Behavior Changed. Did We Actually Help?
As behavior analysts, we are exceptionally good at measuring things.
We can tell you how many times a behavior occurred, how long it lasted, what happened immediately before it, and what consequences followed. We can measure response latency, calculate percentages, evaluate trends, and produce some truly beautiful graphs.
I love a good graph.
But a graph can demonstrate that behavior changed without telling us whether that change actually improved someone's life.
Did reducing a child's crying during transitions help them access activities they enjoy, or did it simply make transitions easier for the adults? Did increasing a teenager's participation in group activities help them develop relationships they wanted, or did it require them to spend more time in situations they found exhausting? Did broadening an adult's interests create new opportunities they valued, or did it take time away from something that already brought them joy?
These aren't arguments against collecting data or teaching important skills. They're questions about what our data actually tell us.
Consider a client whose aggression has decreased to zero. That's an important outcome, particularly when aggression has interfered with their safety, relationships, or ability to participate in daily life.
But what else has changed?
Can they communicate their needs? Do they have more opportunities to participate in activities they enjoy? Are they developing relationships that matter to them? Do they have more control over their own lives?
Or have we simply eliminated a behavior without changing the circumstances that made their life difficult in the first place?
The absence of a behavior is not the presence of a meaningful life.
Nearly 50 years after Wolf asked us to examine the significance of our goals, the acceptability of our procedures, and the importance of our outcomes, those questions remain.
I think back to the teenager who told me they didn't want to work with me anymore. Their perspective changed the direction of treatment, and they ultimately considered their discharge a success.
I don't have a perfect answer for reconciling every competing priority. But I do think Wolf's article challenges us to remain curious about the assumptions we bring into our work.
We can demonstrate treatment fidelity, document mastery, and show meaningful changes in behavior. But if we never ask the people receiving our services whether those changes have made their lives better, we're missing something fundamental.
I'll leave you with one question:
When was the last time a client's perspective actually changed one of your treatment goals?
References
Conrad, S. R., & Wincze, J. P. (1976). Orgasmic reconditioning: A controlled study of its effects upon the sexual arousal and behavior of adult male homosexuals. Behavior Therapy, 7(2), 155–166. https://doi.org/10.1016/S0005-7894(76)80271-7
Willner, A. G., Braukmann, C. J., Kirigin, K. A., Fixsen, D. L., Phillips, E. L., & Wolf, M. M. (1977). The training and validation of youth-preferred social behaviors of child-care personnel. Journal of Applied Behavior Analysis, 10(2), 219–230. https://doi.org/10.1901/jaba.1977.10-219
Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11(2), 203–214. https://doi.org/10.1901/jaba.1978.11-203