The Behavior Change Project: A Field Assignment in Empathy Building, Self-Awareness, and Direct Clinical Practice : Field Educator

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Abstract: The author describes the use of a behavior change project implemented in a social work field seminar at the University of Memphis. Students select one of their own behaviors to change and implement an empirical study of their progress in changing the behavior. The project provides the students with an opportunity to put themselves in the client’s place in a way that also assists them with understanding direct practice and evaluating clinical outcomes.

The primary objective of field education is to provide the student with the opportunity to actively engage in professional tasks that supplement, complement, and reinforce the classroom learning experiences. Although the practice of field education is often noted as the most important direct learning experience for students to prepare themselves for applied practice, Hewsen, Walsh, and Bradshaw (2010) found that many new social work practitioners felt less than equipped to handle the changing nature of clinical practice. It is important in social work practice to show empathy towards the client to build rapport but also to maintain self-awareness regarding one’s own biases towards clients as it relates to their clinical progress and goal attainment. This paper describes the use of a behavior change project implemented in a social work field seminar. The behavior change project is a mandatory class assignment for MSW students in the Field III and Field IV seminar courses at the University of Memphis. As part of this project, students select one of their own behaviors to change and implement an empirical study of their progress in changing the behavior. The project provides the students with an opportunity to put themselves in the client’s place in a way that also assists them with understanding direct practice and evaluating clinical outcomes.

Rationale

Evaluating clinical outcomes is currently a central component of effective best practices for clinicians in the field of applied social sciences. With the increase in monitoring clinical outcomes, it has become evident that there are a number of clinician attributes and practices that can enhance client outcomes, including the clinician’s attitude toward the client, the clinician’s ability to be empathic during the therapeutic processes, and the clinician’s ability to appropriately identify and implement positive reinforcement relative to client goal progress and attainment (Antony & Roemer, 2003; Barber, Connolly, Crits-Christoph, Gladys, & Siqueland, 2000; Berg, Wacker, & Steege, 1995; Martin, Garske, & Davis, 2000; Sprenkle, Davis, & Lebow, 2009). Therapeutic processes that include an engaged, empathetic, and supportive clinician (including progress monitoring, providing supportive and corrective feedback, utilizing practices of positive reinforcement, etc.) are essential for effective clinical work.

In an attempt to teach clinicians to create a positive therapeutic environment, the concept of therapeutic alliance has gained popularity within the field of applied social sciences. Therapeutic alliance has been linked to positive results in relation to client outcomes (Barber et al., 2000; Sprenkle et al., 2009). Martin, et al. (2000) define therapeutic alliance as a collaborative bond and sharing of positive affect between the client and the clinician. Research conducted by Martin et al. (2000) indicated that in therapeutic relationships where the clinicians showed empathy, respect, validation, and genuine affect toward the client, positive clinical outcomes were reported at higher levels. Empathy is encompassed by and is an integral part of the process of therapeutic alliance. In 2003, Barker defined empathy as “the act of perceiving, understanding, experiencing, and responding to the emotional state and ideas of another person” (p. 141). As clinicians, we all strive for positive clinical outcomes that show client growth and achievement and will eventually lead to an increase in the client’s opportunities for success. Many times when evaluating outcomes, clinicians tend to blame the lack of client progress on the client’s unwillingness to comply with treatment procedures, suggestions, and interventions. This is especially evident in programs where clinicians are asked to serve an involuntary client population (Cingolani, 1984). Many times clinicians will ascribe poor clinical evaluations of a client to the client’s lack of participation in clinical activities or lack of motivation to work toward the goal. This may be an unrealistic assessment on the part of the clinician. Clinicians can increase the likelihood of successful outcomes by analyzing their level of empathy and compassion toward the client while attempting a personal behavior change. Clinicians need to be aware of their biases toward clients as they relate to their clinical outcomes (client “noncompliance” and “lack of motivation” to change) by experiencing firsthand the difficulty of being a client asked to complete a behavior change activity. Progress monitoring, data collection, and analysis of data related to goal attainment are imperative to ensure that clinicians are employing the best practices for clients. This type of data collection procedure allows the clinician to monitor client progress on a daily or weekly basis in order to determine if interventions are effective. This type of data collection also allows the clinician to make changes in the intervention at any point in time to ensure that the most effective interventions are being employed (Burns, Scholin, Kosciolek, & Livingston, 2010; Foegan, Jiban, & Deno, 2007).

The Behavior Change Project

The behavior change project is a mandatory class assignment for MSW students in the Field III and Field IV seminar courses at the University of Memphis. The behavior change project assignment is a comprehensive activity that will assist the student with the following: growing their empathic responses, improving the therapeutic alliance processes, increasing their awareness of the challenges that clients face that can potentially negatively impact positive progress, and improving the student’s understanding of the importance of data collection procedures in social work practice. The behavior change project is an example of parallel process, a tool that is often utilized in clinical supervision. As students identify their own behaviors and attempt to change them, they become more empathic towards clients who are attempting to change their own behaviors. The target behavior chosen by the student can be a personal behavior that they wish to change, or it can be a behavior that they wish to alter about a member of their family (this assists the clinician in understanding the context of this assignment from either an individual counseling perspective or from a parent/family therapy perspective).When implementing this activity as an assignment in field education, it is important to note that some students may target specific behaviors for change that they may feel uncomfortable sharing in the class setting; they should understand that the personal behavior targeted for change should be one that they feel comfortable disclosing and that falls within the scope of appropriate clinical self-disclosure for peer feedback. Students can be provided with examples (personal target behaviors may include smoking cessation, weight loss, increasing on-time behavior, decreasing negative thoughts, increasing organization skills, increasing self-care activities; child and family target behaviors may include improving their child’s sleep patterns, improving their child’s eating habits, potty training, improving their child’s academic skills through precision teaching practices, improving their child’s school conduct, etc.).

Activity Instructions
For this activity, the students will complete a behavior change project as part of their MSW field education curriculum. This assignment lends itself to be adapted and could potentially be used within the context of a BSW program, as an assignment for a research class, or as a teaching tool in clinical supervision. The students will be required to target a personal or familial need or deficit for change. Through research, the student will identify an appropriate evidence-based intervention to implement with the targeted individual (personal behavior change or familial behavior change). After an appropriate evidence-based intervention is chosen for the project and the student has written an objective and measurable goal for the behavior targeted for change, the student will collect data (including baseline and intervention data) on progress toward goal attainment. During the behavior change project, the student will maintain consistent data collection, will graph the data daily, will monitor the data, and create a graphic display to present during field seminar class. The data collected during this activity will be reviewed, analyzed, and discussed among peers and the seminar professor.

Prior to starting the behavior change project, it is important to gauge student perceptions of clients that are labeled as “noncompliant,” and it is similarly important to gauge the students’ perceptions of the use of data collection procedures in applied clinical practice. During this assignment, the aforementioned information will be gathered via a student self-report questionnaire. This survey is a perception and social validity measurement that will be provided in a pre- and post-test procedure. The pre- and post-test measurements should show growth in the clinicians’ empathic responses toward the client and the challenges that the client may face during the therapeutic change process. The results of the pre- and post-test student-directed questionnaire will also capture any noted growth, understanding, and acceptance in the use of single systems data collection procedures for purposes of monitoring clinical outcomes. The questionnaire will also have a section to elicit open-ended responses from the students related to their opinions about their personal growth at the conclusion of the assignment.

There are several steps in the behavior change project that are defined below. During each step, the professor will teach a skill through the use of direct instruction in order to ensure that the students understand the purpose of the steps within the assignment, are able to display their knowledge within the context of the classroom, and are able to complete the weekly portions of the assignment outside of the classroom. Direct instruction methods employ the concept of “I do,” “we do,” and “you do.” Rosenshine and Stevens (1986) define direct instruction as a teaching method that guides the student learner through the learning process in order to ensure successful outcomes. Direct instruction methods have been linked to positive outcomes in education, have been noted as one of the most effective teaching interventions, and are commonly used in most teaching environments due to their long-lasting effects on student achievement (Hattie, 2009; Snow, Burns, & Griffin, 1998).

First the professor will provide educational instruction with examples and model the appropriate methods for completing the project. The professor then tests the students’ knowledge and understanding of the project (through active student response activities within the classroom, through scenarios and examples analyzed as a group, and if needed, through individualized support to ensure that the students understand the project being implemented). The final phase of direct instruction is to allow the students to start the behavior change project and monitor findings during field seminar while providing positive reinforcement for appropriate programming in addition to corrective feedback in order to remediate skills not learned.

Initiating the behavior change project includes an eight-step process. Each step is explained in detail below. This eight-step process does not have to be completed in the context of one seminar class, and it is highly encouraged to take each step and review the assignment across several days to ensure student competency in the assignment details.

Step 1: Identify a target behavior and write objective and measurable treatment goals.

Practice identifying an appropriate target behavior using a sample scenario. Discuss that clients might have many presenting issues, but as clinicians we must triage client needs and determine what should be addressed immediately and what can be addressed in a long-term treatment procedure. The concept of therapeutic alliance is an important part of this discussion, and the professor should spend time on ensuring students understand that treatment goals should be established with the client, not for the client.
Explain the importance of identifying appropriate treatment goals based on client needs while also employing concepts of self-determination.
Discuss goal setting and writing measurable goals. Discuss what defines an appropriate treatment goal, define target behaviors, and discuss aspects of goal writing, including the following: observable goals, measurable goals, goals defined in explicit terms, and goals that are identifiable across clinicians (Cooper, Heron, & Heward, 2007).
Practice treatment goal identification and goal writing with sample scenarios.
Once the students have mastered the practice in session, have them identify an appropriate target behavior for their project (a brief description of the participant, a description of the target behavior, and a brief explanation of why the behavior was targeted for change) and write an appropriate treatment goal.

Step 2: Discuss preference assessments, data collection procedures, and how to graph data.

Expose students to preference assessment procedures and identify ways to motivate the client toward success. Preference assessments can include forced choice preference assessments, rank order preference assessments, and a preference inventory that the client completes on his or her own (Berg et al., 1995).
Have students practice preference assessment techniques in supervision through role-play activities with a peer. Practice forced choice preference assessment procedures, rank ordered preference assessments, and preference assessment inventory procedures.
Once the students have shown success in these preference assessment procedures, each student will identify (through a preference assessment of their own choice) reinforcers that they feel will motivate her or him toward change. They can also utilize data collected during the practice sessions based on their responses in the role-play.
Explain methods of data collection and ways to gather data in the applied setting. Students will be exposed to the data collection methods utilized in direct observation (e.g., frequency, latency, duration, partial interval, whole interval). Discuss the need to look at the target behavior to determine the most appropriate data collection method to use in the practice setting.
Each student practices data collection and graphing data based on a scenario in field seminar class. Check for accuracy and practice until students show a high level of competency. The use of YouTube videos is an excellent teaching tool related to data collection practices (give the students a target client and target behavior to monitor in the YouTube video and ask them to collect data on the behavior). This is a great way to monitor students’ abilities and accuracy in data collection practices. Once the data is collected in field seminar, guide the students through graphing the data in Excel. Make sure you explain the appropriate way to identify parts of the graph axis titles, phase lines, and the use of line graphs for this type of assignment. Allow the students to practice to competency.
The student must now determine what is the best data collection method and measurement to use for their own behavior change project.

Step 3: Students start baseline data collection.

Discuss the importance of having a baseline prior to starting the intervention so that progress can be easily identified.
Encourage the students to spend the next week to two weeks gathering data on the target behavior prior to implementing an intervention.
During the baseline data collection, the student will bring data collection to field seminar class in the form of a graph so that the professor and the peers can analyze as a group and provide feedback about data collection practices, graphing abilities, and stabilization of the data.

Step 4: Students research Evidence Based Interventions (EBI) for the target behavior.

Assist the students in understanding the reason for utilizing EBI in practice and locating information on appropriate EBI for the target behavior. The baseline data collection process is a great time to have students start investigating appropriate EBI for the target behavior in peer reviewed literature. The students will bring in literature that they have found on similar target behaviors and EBI used to correct the identified target behavior. This is a great way to expose students to journal searches, research in the applied setting, and linking research to practice.

Step 5: Students identify possible obstacles to project.

The students are prompted to hypothesize obstacles that they foresee in the completion and attainment of the targeted goal. The students are also prompted to review issues that were noted as limitations in some of the research that they studied and discuss how those limitations may impact their behavior change project. This will assist the students in understanding that the intervention may need to be modified or changed during the intervention phase if progress is not noted or if the target behavior moves in a counterproductive manner. It also prepares the students to problem-solve to eliminate obstacles and ensure greater success in the therapeutic process.

Step 6: Students start EBI, continue data collection on target behavior, graph data daily, and maintain a therapeutic daily journal about the behavior change process.

Students start the EBI after a minimum of five data points have been obtained in baseline or once the baseline data is stable at a steady rate.
The students will continue data collection on the target behavior during the intervention phase. During the data collection process, the students will graph progress daily in order to determine if the EBI is proving effective for the client. The results and daily data are shared in field seminar class for analysis, feedback, and processing the activity.
The students are also prompted to maintain a daily field journal that allows them to reflect on the behavior change project. The journal can include reflections about their feelings during the change process, obstacles that they face while trying to complete the project, and a 1–10 scale (stress thermometer) to identify the level of stress that the intervention process caused each student on a daily basis.

Step 7: Students bring their graphic displays of data to field seminar, report on their progress toward goal attainment, discuss obstacles in treatment, and provide journal-entry feedback about the process.

The students will bring in their graphic display of data collected during the behavior change project and will report on the progress to their professor and peers within the context of the seminar course. This process will be similar to a staffing that will happen in the applied setting when working with clients in the clinical environments.
Students will process the project, identify ways to improve outcomes (continue intervention, change intervention, or modify intervention), and continue collecting data until the conclusion of the field seminar course.
Discussions related to field journals are also important and will serve as a way to guide and support the students through the behavior change process.
Students are reminded of the reinforcers they are working toward (previously identified in the preference assessment), while also being provided positive reinforcement to continue progressing toward the goal. The professor should also provide weekly reinforcement to each student in order to maintain the motivation to continue the project and work. Pairing a tangible reinforcement with verbal praise is important in increasing successful outcomes.

Step 8: In class, peers and supervisors provide feedback (e.g., corrective, explorative, etc.), positive reinforcement, offer empathy related to students’ progress toward their goals, and discuss trends found in data. This supervision and staffing process continues until the end of supervision.

Group discussion in the field seminar class is an excellent way to process students’ needs in this project, brainstorm ways to improve outcomes, analyze data as a group to identify trends in data, and obtain supervision from other professionals and colleagues in order to ensure that the student is providing excellent services to the client. Group discussion is a great practice skill and should be encouraged outside of the field seminar class. Discuss the importance of confidentiality in this type of discussion and staffing, but inform the students that supervision and colleague input can be invaluable in an applied clinical setting.
At the conclusion of the assignment, persons who attained their projected treatment goal are given their preferred reinforcer, verbal praise, and a tangible certificate noting successful outcomes. Students who did not attain their established goal but did make every effort to work on improving outcomes through analyzing data, changing of intervention, accepting feedback, and working toward the goal are also provided positive reinforcement in the form of verbal praise (for accomplishing some improvements even if the goal was not attained). The professor and peers will take turns providing information about one positive outcome of each student’s project in light of the lack of goal attainment (strengths based), and peers and the professor will give these students a certificate of participation as encouragement to continue the personal project.

Example
During the most recent field seminar class provided where the behavior change project was implemented, a student clinician chose to target her young daughter’s school tardiness as the behavior for change. The student gave a brief description of the behavior targeted for change and a brief history that noted her daughter was diagnosed with ADHD (predominantly inattentive type). The student went on to describe that the child’s ability to be on-time for school was actually jeopardizing her ability to stay enrolled in the school she attended, as it was not the neighborhood school and the student had to participate in a school lottery in order to obtain a spot in this preferred school. Excessive tardiness would result in her being removed from the school program. The student mentioned that previous interventions had been attempted and were unsuccessful, but that this was based on subjective information, and no EBI was previously used, nor was data collected on previous interventions. The student then identified and selected an appropriate EBI noted as successful for clients with an ADHD diagnosis (visual schedule and visual prompting). The student obtained baseline data related to the frequency of tardy behavior over a two-week period. The student informed her daughter of the upcoming intervention and its purpose. She created an appropriate visual schedule (checklist) of morning routine activities that would assist in keeping her daughter on-task during the morning routine. She trained her daughter to use the intervention (role-play), and then the student began the EBI while continuing the data collection procedures. Results of the behavior change project for this student were positive. Her daughter’s rates of on-time behavior increased to 90 percent over the six months (this timeframe was chosen by the professor and reflected the hours the students would serve in field for one semester of field programming). The student went on to explain that the child won a “most improved award” at school for improving her on-time behavior, the child was able to stay at the preferred school, and the student’s level of stress decreased during the intervention procedure. The student’s field journal entries did note some obstacles that were experienced during this activity and were processed in the context of the seminar class by analyzing the data and discussing intervention alterations to improve success. One of the noted obstacles was that the child needed daily prompting to review the visual schedule, but after four weeks of the daily reminders, the child was able to follow the routine with limited prompting by the student. This student also used a preference assessment that noted that a motivator for the child was a trip to the zoo with her mother. The original goal set by the student was that the child would receive a trip to the zoo after she completed two weeks of on-time behavior. This was the original established treatment goal for the child; however, after two weeks in the intervention phase with no progress toward the goal, the student rewrote the goal so that the reinforcer would be provided after one week of on-time behavior in order to build in behavioral momentum for her daughter and encourage success through access to a reinforcer. After the goal was modified, the daughter accessed the reinforcer after the first week, and the student informed the child that they would incrementally raise the criteria for reinforcement access as goals were obtained. This proved to be very effective, and the daughter was receiving a trip to the zoo after maintaining four consecutive weeks of on-time behavior. This was a positive outcome that reportedly continued on far after the supervision project ended.

Measuring Progress

Progress and growth of the student learner is analyzed in a number of ways during this activity. The first method for measuring student progress during this project is the use of a social validity measurement questionnaire that will identify the student’s beliefs and perceptions about client noncompliance and their perceptions and opinions about the use of data-collection procedures in the applied setting. This will be provided in a pre- and post-test procedure.

Another method used in measuring student progress is a single system research model to gauge the student’s ability to identify a need, collect data, research and choose an effective EBI to address the need area, maintain consistent data collection on the target behavior, and analyze the data for progress. The student is asked to choose one of his or her behaviors, or one of a close family member’s, that they wish to target for change. The use of single systems processes for this assignment opens the clinician’s eyes to the need and importance of data-driven decision-making in clinical evaluations. This also exposes the student clinician to the possible feelings many clients may have when asked to employ intervention methods and data collection procedures in the applied setting. This assists the student with increasing empathy toward clients who appear to be “noncompliant” or who fail to consistently comply with requested techniques and interventions.

As part of the single systems research model, the students also participate in weekly class-wide staffing of their personal progress on target behavior change. Each student submits collected data that has been graphed for purposes of visual analysis and presents to the class a short synopsis of the target behavior, intervention chosen, and current data on the behavior change project. This is a great opportunity for students to present findings, review and analyze data collection, and obtain support and feedback from peers related to evaluation outcomes and changes in the current intervention plan. This process places the clinician in the role of the client, experiencing how the client feels when being assessed and analyzed when reporting progress or lack of progress toward goal attainment.

The final assessment method for this intervention is a daily journal activity. The students are instructed to maintain a daily journal related to the behavior change project, their perception of the progress of the intervention process, obstacles to the behavior change project, and a method of analyzing feelings about the intervention project (on a 10-point scale).

Connecting to the Field Placement

Although the exercises in the behavior change project take place in the field seminar, there is a close connection with field placements. Prior to the beginning of the fall semester, the seminar teacher (the field director) informs upcoming field instructors about the behavior change project. Students review findings in the field seminar course not only with the seminar teacher but also in weekly supervision with their field instructor. Field instructors are provided the rubric for grading the assignment as a guide to implementation, although the seminar teacher gives the grade. In addition to helping field instructors understand some of their interns’ personal challenges, the course teaches field instructors and students about literature review, being consumers of research, understanding goal and treatment plan writing and data collection practices, and graphing data.

In Field IV the behavior change project moves from assessment of the student’s personal behavior to assessment of client behaviors. Maintaining client confidentiality, the students present in the seminar their process of researching, investigating, and identifying an EBI to address client needs. Progress toward client goals is monitored and reviewed in monthly seminar classes as well as in supervision by the field instructor.

Conclusion

Teaching skills of empathy and self-awareness and supporting the client throughout the therapeutic process through careful data collection are needed in order to improve successful outcomes in therapy. As evident in the research on effective best practices in education, direct instruction methods have proven to be an effective pedagogical practice for training and educating others. The behavior change project is the perfect combination of evidence-based activities for purposes of teaching a skill embedded in an activity that enhances best clinical practices of students and improves the clinical practices of the social workers of the future. Many students identified the project as a “thought-provoking” and “eye-opening” experience that exposed them to the obstacles clients face while trying to follow clinical advice and intervention procedures.

The behavior change project is a teaching tool that can be adapted and utilized in multiple settings. This project can be helpful in formal clinical supervision, in the context of a field seminar class, for a social work skills course, or in the context of a research class focusing on single subject designs. This article can serve as a guide for preparing teaching practitioners to utilize this project in the learning environment to enhance student understanding of the change process, increase empathy, and improve therapeutic relationships while teaching students about gathering evidence.

Additional Resources

Real Cases: Integrating Child Welfare Practices across the Social Work Curriculum by C.S. Cohen, T. Gimein, T. Bulin, & S. Kollar (2010)

The Journal of Applied Behavior Analysis web-based archives

ABC-UBI’s Least Restrictive Behavior Interventions: Rules and Individual Strategies

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Field Educator: A Scholarly Journal from the Simmons University School of Social Work