TL;DR

A self-paced ACT module (DNA-V framework, ~60 min, Storyline 360) was delivered to 3 RBTs, followed by contingent BST if performance stayed below criterion. ACT alone produced short-term boosts in two participants and minimal change in the third; 2 of 3 ultimately required BST to reach acceptable performance. Self-report measures of psychological flexibility (PPFI) and job satisfaction (MSQ) did not shift meaningfully. Takeaway: the verbal/contextual repertoire targeted by ACT and the overt contingencies addressed by performance management appear to work as a package — sequencing may matter less than ensuring both are present.

Background & rationale

• ABA service environments are inherently stressful (Symes et al., 2006); RBTs face documented challenges to competency, compensation, and retention (Nastasi et al., 2024).

• Behavioral staff training has historically managed overt contingencies but rarely addresses the private events (thoughts, feelings, rule-following) that interfere with skill use.

• ACT — derived from Relational Frame Theory (RFT) — targets psychological flexibility. This study used the DNA-V model (Discoverer, Noticer, Advisor + Values; Hayes & Ciarrochi, 2015), a streamlined alternative to the traditional Hexaflex chosen for brevity and reduced technical-language load.

• Prior work (Little et al., 2020; Pingo et al., 2020, 2022) introduced ACT after performance management. This study inverted the sequence — ACT first, BST only if needed — to test whether ACT alone could close performance gaps when expectations were already established.

• Target skills were drawn from Lugo et al. (2017): operationalized presession pairing skills linked to therapeutic alliance and instructional control.

Design & participants

• Design: Concurrent multiple probe across 3 participants.

• Setting: Single clinical site of a multi-state ABA agency, Southeastern US.

• Participants: 3 RBTs aged 23–24 (1 Black female, 1 Hispanic male, 1 Hispanic female), each with <2 years RBT experience.

• Inclusion criteria: Aggregate ≤3 targeted pairing skills during a 5-min observation; ≥30 days RBT experience in the past 6 months.

• Measurement: 5-min observations during pairing/naturalistic teaching periods prior to DTT, 2–3x/week, across two clients per RBT.

• IOA: 93% aggregate across 30% of observations.

Intervention components

ACT e-learning module (delivered first)

• Self-paced course in Storyline 360, ~60 min, completed independently.

• Sequenced: Two Sheets of Paper exercise (Flaxman et al., 2013) → ACT rationale → Advisor (Master Storyteller metaphor for defusion) → Noticer (mindfulness breathing) → Discoverer (adapted Quicksand metaphor) → Values clarification + FEAR/DARE acronyms (Harris, 2019).

• Language deliberately avoided naming pairing skills to minimize demand effects.

BST (delivered contingently)

• Triggered when ≥2 of 3 target skills were ≤3 occurrences for 3 consecutive sessions post-ACT.

• Adapted from Lugo et al. (2017): instruction → modeling → rehearsal → corrective/positive feedback, repeating until accurate demonstration of all three skills.

Key findings

• P1: Brief post-ACT increase, decayed toward baseline. BST produced sustained gains; partial maintenance.

• P2: Strong post-ACT response; never dropped low enough to trigger BST. Notably, P2 reported being unaware of the DV until debrief — suggesting the ACT-only effect was not driven by explicit awareness.

• P3: Minimal ACT response; BST produced the largest and most sustained increase of any participant.

• Across participants: Praise was the least responsive skill regardless of intervention. Describe showed the most growth, followed by Create.

• Self-report measures (PPFI, MSQ): No consistent change. P1's job satisfaction dropped slightly; P2 and P3 ticked up marginally. No meaningful shifts on any PPFI subscale (avoidance, acceptance, harnessing).

Practical implications

• ACT alone is insufficient when the desired performance is environmentally constrained or has not been explicitly trained and reinforced.

• Sequencing (ACT first vs. BST first) likely matters less than ensuring both verbal-contextual and overt-contingency components are addressed.

• Brief didactic ACT may produce short-term motivational shifts but is unlikely to sustain skill change without supportive performance management infrastructure.

• Skills with clear environmental opportunities (describe, create) are more responsive to brief training; opportunity-bound skills like praise — contingent on specific client behavior — likely require targeted in-situ instruction (and possibly explicit teaching of opportunity recognition as its own skill).

• Organizations investing in ACT without addressing system-level stressors (compensation, scheduling, supervision quality) should not expect movement on job satisfaction or psychological flexibility metrics.

Limitations worth noting

• Applied setting volatility: Scheduling changes, client reassignments, and supervisory conflicts constrained data collection (P2's clients were reassigned/discharged, ending follow-up early).

• Brief ACT module: Designed for resource-lean accessibility, but the truncated dose may have undercut sustained effects.

• DV awareness: The consent process referenced rapport-building broadly. Pairing skills were never explicitly named, but partial awareness can't be ruled out.

• No formal social validity measures — only anecdotal feedback collected at debrief.

• Limited skill battery: Only 3 of Lugo et al.'s (2017) pairing skills were targeted. These reflected the participants' observed deficits, not a comprehensive set.

• No "correct" target rate: There is no empirically established threshold for adequate pairing skill rate per session. Criteria were derived from prior literature, not normed.

Citation

Denegri, S., & Catrone, R. (2025). Using Acceptance and Commitment Training and Behavior Skills Training to Enhance Therapist Pairing Skills. Behavioral Interventions, 40(4), e70050. https://doi.org/10.1002/bin.70050