SELF KNOWLEDGE & SELF CARE

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Cultivating Self-Knowledge to Improve Self Care Behaviors:
A Behavior Analytic Intervention
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Alicia M. Anderson, M.S., BCBA
Endicott College

Dissertation Submitted in Partial Fulfillment of the requirement for the Degree of Doctor of
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Philosophy Applied Behavior Analysis

Endicott College, Beverly, MA
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© 2020

Alicia Anderson

ALL RIGHTS RESERVED

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Abstract

Dissertation Advisor: Val Demiri

The study sought to cultivate participants’ self-knowledge (as defined by understanding

one’s background and influences, being able to discriminate one’s own behaviors, recognizing

one’s thinking or conceptual self as distinct from one’s observing and perspective taking self,

understanding one’s values, and setting realistic goals) through the lenses of Applied Behavior

Analysis (ABA), Acceptance and Commitment Training (ACT) and Relational Frame Theory

(RFT) to improve participants’ engagement in self-selected self-care behaviors. Four adult

participants meeting criteria for study entry with deficits in engaging in self-care behavior as

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assessed through self-report, modified Performance Diagnostic Checklist (PDC), the Maslach
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Burnout Inventory (MBI), and a Self-Knowledge Assessment (developed specifically for this

study) were recruited. Intervention included an informational Functional Behavior Assessment

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(FBA) and a behavior skills training (BST) with ACT strategies (present moment awareness,

values, committed actions, acceptance, defusion, self as context). Engagement in self-care

behaviors was measured in a multiple base-line design with probes. All participants improved in
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engagement in self-care behaviors, emotional exhaustion scores, and total self-knowledge scores.

Cultural and ethical considerations are also discussed.

Keywords: Applied Behavior Analysis, self-care, self-knowledge, Acceptance and

Commitment Training (ACT), Relational Frame Theory (RFT), verbal behavior, rule-governed

behavior
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Dedication

I would like to dedicate this project to my parents (Derron Anderson, Sr. and Melissa

Anderson) two people whose wisdom, love, understanding, work ethic, and sacrifice for their ten

children began my journey into academia and ultimately behavior analysis. Thank you for

everything that you have done and continue to do. To my seven adult siblings (Sean Anderson,

Tia Anderson, Derron Anderson, Jr., Isiah Anderson, Christina Anderson, Tiffany Anderson, and

Kyle Anderson) – it is such an honor and privilege to share a life-long bond with you all; to the

two most amazing and inspiring children in the world, my youngest two siblings (Kendall

Anderson and Chanel Anderson) – you are the air that I breathe and the reason why I live. And to

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my two best friends and mentors, Timothy Rogers (life partner) and Yolanda Anderson (Aunt) –
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I am beyond grateful to have you in my life.
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Committee and Acknowledgements

Committee Chair: Val Demiri, PhD, BCBA-D

Committee Members: Mary Jane Weiss, PhD, BCBA-D & Thomas Zane, PhD,

BCBA-D

Reader and Editor: Colleen Suzio, M.S., BCBA

I would like to thank my academic advisor, Val Demiri, for her mentorship and support,

for shaping my research interests, expanding my knowledge in the field of ABA, and aiding in

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both my personal and professional development. Thank you to Mary Jane Weiss whose immense
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capacities for encouragement, concern, and compassion for all students are among the greatest

that I have seen in academia. Thank you to Thomas Zane for his time and support as a committee
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member.

Thank you to Colleen Suzio and Gabrielle Morgan for their time and generosity as a

reader and editor of this manuscript and my dissertation defense respectively.

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I would also like to thank the Endicott PhD Cohort 4 and the Applied Behavior Analysis

department at Endicott for helping to create an environment where forward movement and

completion were more and more attainable.

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Table of Contents

Title page .................................................................................................................................. i

Copyright .................................................................................................................................. ii

Abstract ................................................................................................................................... iii

Introduction ................................................................................................................................1

Social and Historical Context ...............................................................................................1

Self and Verbal Behavior ......................................................................................................5

Self and Relational Frame Theory (RFT) .............................................................................8

Self and Acceptance and Commitment Training (ACT) ....................................................10

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Self-Knowledge ..................................................................................................................15
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Self-Care .............................................................................................................................16

Performance Diagnostic Checklist (PDC) ..........................................................................18

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Maslach Burnout Inventory (MBI) .....................................................................................19

Self-Knowledge Assessment (SKA) ...................................................................................20

Purpose................................................................................................................................21
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Research Methods ....................................................................................................................21

Results ......................................................................................................................................35

MBI .....................................................................................................................................35

PDC .....................................................................................................................................39

SKA.....................................................................................................................................46

Self-Care Behaviors ............................................................................................................65

Discussion ................................................................................................................................74

Cultural Humility and Ethical Considerations .........................................................................81

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References ................................................................................................................................84

Appendices ...............................................................................................................................91

A. Modified Performance Diagnostic Checklist .................................................................91

B. Maslach Burnout Inventory............................................................................................95

C. Recruitment Flyer ...........................................................................................................98

D. Self-Knowledge Assessment..........................................................................................99

E. Weekly Check-In Forms...............................................................................................109

F. Social Validity Form.....................................................................................................113

G. ACT Strategies .............................................................................................................119

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H. Participants’ Treatment Plans ......................................................................................127
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I. Informed Consent Form.................................................................................................155

J. IOA Form ......................................................................................................................158

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K. Treatment Integrity Checklist ......................................................................................159
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SELF-KNOWLEDGE & SELF-CARE 1

Cultivating Self-Knowledge to Improve Self Care Behaviors:

A Behavior Analytic Intervention

Applied Behavior Analysis (ABA) is a scientific discipline concerned with applying

empirical techniques based upon the principles of learning to change behavior of social

significance (Baer, Wolf, & Risley, 1968). In a general sense, social significance describes the

impact that phenomena have on society, or the larger social structure in which individuals live.

In ABA the social significance of behaviors targeted for change denotes the effect that behavior

has on the environment (and vice versa) and the ability that it provides a person to act, live, and

adapt within a community to access sources of reinforcement and live full lives according to

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what is valued. ABA as a science has far reaching implications and influence and has been
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proven to have great impact on populations of individuals with intellectual and developmental

disabilities as well as various psychiatric illnesses (Ayllon & Michael, 1959). But the field of
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ABA has little visibility and shorter reach when it comes to the empirical analyses of complex

social issues and the behaviors of neurotypically developing individuals. In the current social

climate, in which the short comings of historic systems of control are being exposed and the
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desire for social change and progress are the drivers of mass action as well as the actions of

individuals, it is imperative that ABA, with its powerful technologies, stands at the forefront of

these movements to drive behavioral change within these systems and within the lives of

individuals.

It is impossible to discuss behavior analysis and complex systems of human behavior

without discussing the contributions of Burrhus Frederic (B.F.) Skinner. In his book Science and

Human Behavior, Skinner (1953) sets the foundation on how human behavior is viewed and how

behavior can be described, predicted, and controlled. According to Skinner, the science of human
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behavior can be applied to all behaviors. In Radical Behaviorism, the philosophy of the science

of human behavior, all behaviors include those actions and responses that can be seen, in

addition to those that are not directly observable (those that occur underneath the skin – e.g.

thoughts, feelings, emotions, images, attitudes, judgement, etc.) though they may be difficult to

define, measure, and study as dependent variables (Tourinho, 2006).

The underlying purpose of empirical investigation into behaviors (or the science of

human behavior) is to understand causes and effects. By discovering and analyzing the cause,

behaviors can be predicted to the extent that they can be manipulated and controlled. One issue

then, is that the ability to manipulate and control is often taken out of the hands of individuals

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and placed into the hands of many controlling agencies including government and law, economic
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agencies, religious agencies, educational institutions, and psychotherapy to name a few (Skinner,

1953). Skinner discussed how these systems often use punitive approaches, laws, policies, and
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rules to restrict the behaviors of individuals. Other methods of controlling behaviors can include,

shaping, and reinforcement of behaviors that are desired by groups, but that may not fit within

the value systems of individuals. In the current era and social context, a science of human
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behavior can help people to control their own lives, environment, and behaviors to live more

closely to the things that they value.

Because human beings are by nature social creatures, social relationships are the

foundations on which human lives, dreams, passions, hopes, desires, and behaviors are built.

These social relationships can include interactions with family members, friends, community

members, society members, colleagues, or other affiliates. These relationships can also include

those of a speaker and a listener (Skinner, 1957). Within social interactions are episodes of

antecedent stimuli, behaviors, actions or responses, and consequences. Consequences derived

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from interactions within these relationships are important to building one’s current behavioral

repertoire and propensity for future behaviors (Skinner, 1953). They are also important to

creating the cultural context and social environment in which people live. In the modern world,

these consequences are critically important regarding the form of interactions as well, including

those that happen face to face and those that happen virtually (e.g. through social media, video,

text, phone calls, etc.). These relationships and interactions can be pivotal to one’s quality of

life, socialization, physical health, and mental health, but arguably the most important

relationship that any person can have is the relationship with themselves.

The self as both a conceptual framework and a very tangible environmental product

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seems vast yet contained; abstract yet concrete. Self has been the subject of many philosophical
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and psychological inquiries as well as the prefix to many constructs that can be hypothetical in

the absence of behavioral correlates (e.g., self-esteem, self-confidence, self-awareness) (Gulick,

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2014). Early philosophies of “self” focused on consciousness, mental states, and qualia or

experiences that distinguished one person from another. Consciousness was used to describe

individuals’ awareness of themselves, their internal environment, and both internal and external
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experiences. Philosophically, self was also connected to “soul” and other explanations which did

not necessarily lend themselves to factors that were directly observable, objectively defined, or

directly subject to scientific analysis (Skinner, 1953), but that were attempts at understanding the

experience of “self” in relation to the world (Gulick, 2014).

With influences from philosophy, in the earlier days of psychology, prominent figures

such as Sigmund Freud described the self as the “object of one’s narcissistic or cathectic

investments” (Kunzendorf, 2017). Self was seen as a concentration of attitudes and

energies (McIntosh, 1986) and Carl Jung described the self as a product of individuation, an
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integration of different personalities (Henderson, 1964). For Abraham Maslow the actualization

of self was at the top of his hierarchy of needs, preceded by self-esteem (Kunzendorf, 2017). In

psychology, thoughts were seen as such a critical component of self that the cognitivism

movement proposed making the study of thoughts a field of its own (Lilienfeld, 2010). In

psychology, as in philosophy, conceptualizations of self were based on hypothetical constructs

and teleological explanations (e.g. cognitivism, mentalism, and literal dualism) of the self.

Though Radical Behaviorism is rooted in philosophy and psychology it moves beyond

teleological explanations and hypothetical constructs. Radical behaviorism emphasizes the study

of phenomena as behaviors rather than hypothetical constructs and mental states. B.F. Skinner

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defined the self as an organized system of responses; a relationship among modes of action; a
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vessel contained within the skin which acts overtly on the environment, but which also engages

in behaviors underneath the skin such as thoughts, feelings, and emotions for example (1953).
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These thoughts, feelings, and emotions are referred to as private events, and these private events

are subject to the same contingencies as observable behaviors. With respect to the

self, one’s private behaviors can be as informative as one’s public behaviors. However, as
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mentioned previously, measurement of private events can prove difficult, especially in the

absence of accurate self-report by the individual or expensive instrumentation to

measure physiological correlates of private events (e.g. brain or neurological activity, heart rate,

skin responses, etc.). And even when such physiological measures are possible, discrimination of

the differences and one to one correspondence between private events and physiological

activities are nearly impossible to pinpoint (Skinner, 1953). For example, physiologically,

anxiety can be the same as happiness or anger. Or, expressions of happiness and sadness may

look different overtly, but physiologically may be similar (An et al, 2018).
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Self and Verbal Behavior

Included in these private events are verbal behaviors, specifically covert verbal

behaviors. In his book, Verbal Behavior (1957), Skinner sets the foundation on how language is

discussed from a behavior analytic framework. Verbal behavior is defined as behavior that is

reinforced through the mediation of another person, or the self, when self serves as the speaker

and the listener in a verbal behavior episode. In an observation of a verbal episode, one might see

changes in the immediate environment with respect to the verbal behaviors of others, but there

are also covert levels of verbal behavior that are only accessible to the individual experiencing

their own thoughts, emotions, and private language (Skinner, 1957). As mentioned previously,

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reporting of one’s own private events is a challenge that behavior analysts face today.
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Taylor and O’Reilly (1997) described two classifications of private events: internal

sensations such as bodily functions and covert behaviors such as self-rules. In fact, Skinner also
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described the proprioceptive and interoceptive and exteroceptive stimuli as a variety of private

stimulation one may experience without public accompaniment (Skinner, 1953). When

discussing the challenges in accessing covert behaviors through self-report, the authors discuss
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that self-report on its own is insufficient in establishing a functional relation between covert

behaviors and non-verbal behaviors. To demonstrate a functional relationship, the authors note

that it is necessary to show the functional equivalence of overt (self-report) and covert self-rules

by showing that performance is similar under both overt and covert conditions. And that overt

self-reports are outward manifestations of covert rules. In their study, by effectively blocking

covert behaviors with overt non-sense syllables, they demonstrated that covert behaviors and

self-rules when used as external self-directives can produce corresponding non-verbal behaviors.
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Hence covert behaviors in the form of self-instruction can control responding under overt,

covert, and blocking conditions.

Taylor and O’Reilly’s (1997) study was conducted with individuals with mild

developmental disabilities. But we cannot ignore these implications for those who have more

developed language repertoires since private events are language based (Faloon & Rehfeldt,

2008). From a monistic perspective, thoughts are no different from vocal responses. Only one is

accessible to individuals. Thoughts and rules are related to one’s “sense of ‘self’” which can be

verbally constructed (Levin, Hayes, & Vilardaga, 2012). This is why verbal processes engaged in

by individuals may contribute to human suffering, such as increased contact with aversive

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stimulus functions; narrowing behavioral repertoires; and rigid, ineffective patterns of behaviors
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based on rules and a verbally constructed sense of self. Understanding rule governed behaviors

as they relate to verbal behavior and private events is important because we learn that individuals
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don’t directly have to experience contingencies to know what to do and what not to do.

Direct contingencies are important, but so are the contingencies that language itself

establishes. Mattaini & Thyer (1996) discuss how rule governance is crucial in learning of
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complex behaviors and social practices and identifying the potential consequences of behaviors

and actions. Rules, once learned, are sometimes relatively insensitive to actual contingencies in

effect. This notion has clinical significance when working with neurotypically developing adults

because direct environmental contingencies are not always apparent. Verbal behavior comes to

have power over much of our behavior and because of private behaviors we also see how people

come to create rules about self that may not be functional. These rules can be about self or others

(thus prejudices, racism, discrimination, self-worth etc.).

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Human beings are immersed in a “sea of concurrent contingencies” (Malott et al., 1993,

p. 378). “Because of the interlocking nature of contingencies, interventions focused on a single

element may fail if other powerful elements tend to return the system to previous homeostasis”

(Mattaini & Thyer, 1996, p. 24) Certain complex behaviors and systems of behaviors ordinarily

cannot be studied in a laboratory. Even if they could be, by amputating these entities from the

environmental network within which their members are embedded, the phenomena observed

would no longer be those in which behavioral scientists are interested (Mattaini & Thyer, 1996).

This does not mean that these things should not be studied. Behavior Analysts should employ

additional methods which include organized observation, controlled experiments, development

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and evolution of conceptual frameworks, and theoretically guided observations.
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Because of the limitations of measurement when it comes to private events, it does not

mean that these behaviors should not be studied (Skinner, 1953). In reality, acting within a verbal
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community requires making inferences about the behaviors of others even in the absence of

influences that are not always apparent. Therefore, it is imperative to develop the science that

can study these private behaviors other than physiological or medical measures. Often times
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private events are measured through self-report, permanent product, direct observation, or

corroborating environmental events or stimuli that the verbal community can access. These

forms of measurement are deemed appropriate depending on the circumstance (e.g. collecting

social validity of a study is held in high regard as a best practice of conducting research and this

is all self-report). It is important to use the best technologies and methodologies available within

ethical guidelines to study these phenomena. Though the analysis of verbal behavior and private

events as put forth by B.F. Skinner has been instrumental in understanding language and private

events as private behavior is subject to the same contingencies as all of behavior, some have
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argued that verbal behavior fell short in terms of explaining how individuals relate and equate

experiences (Gross & Fox, 2009). Building on to the behavioral view of language as per Skinner,

others took this analysis further in Relational Frame Theory (RFT) (Hayes, Barnes-Holmes, &

Roche, 2001).

Self and Relational Frame Theory

Skinner defined rules as contingency-specifying stimuli, but there was no definition to

explain what specifying meant or how it develops (Parrot, 1983). Acceptance and Commitment

Therapy (ACT) and Relational Frame Theory (RFT) developers concluded that they needed a

new and more robust contextual behavioral account of human language and cognition that could

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lead to empirical advances, both basic and applied (Levin, Hayes, & Vilardaga, 2012).
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Prominent figures like Murray Sidman, Jack Michael, Steven C. Hayes, Simon Dymond, and

Dermot Barnes took Skinner’s analysis of verbal behavior and moved it forward. Since private
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events and covert behaviors are viewed as language based, they can therefore be conceptualized

by relational frames (Hoffman et al. 2016). Relational Frame Theory (RFT) is a theory of

language aimed at understanding and influencing human cognition (Hayes, 1991). It is a

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behavior analytic account of human language and cognition that is about relating. RFT contends

that arbitrarily applicable relational responding is the key process in human verbal behaviors

(Dymond, May, Munnelly, & Hoon, 2010).

Both verbal behavior and RFT can be linked to a faulty “sense of self” and therefore

human suffering as some properties of language can promote suffering (Barnes-Holmes, Hayes,

& Dymond, 2001). For example, if a person were to literally believe that they were their negative

thoughts and emotions, or that these thoughts and emotions were defining characteristics that

permanently dictated their behavior, this could be harmful and maladaptive. Self-deprecating
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statements may be evidence of private events and self-rules that affect behavior, when problem

behavior continues at some level even when programmed contingencies are in effect because

they act as motivating operations for problem behavior (Hoffman et al., 2016). Relational frames

can be combined to generate verbal rules that govern behavior and allows people to organize,

predict, and control how consequences are obtained in relation to the context. This way, they can

anticipate future situations without having experienced them. These relations are learned because

of RFT and verbal behavior.

One form of relating is equivalence, which discusses how derived relations (untrained

relations) can emerge from relations that are directly trained. Verbally able human beings learn

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to respond relationally to physical properties of stimuli in the environment. They can also learn
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to respond relationally to objects or events when the relation is not only defined by physical

properties, but also by additional contextual cues (Sidman 1994, Hayes, Barnes-Holmes, &
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Roche, 2001). Specific kinds of arbitrarily applicable relations are called relational frames and

have the properties of mutual entailment, combinatorial entailments, and transformation of

function. In the case of private events such as thoughts and feelings, when a person experiences a
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negative event (e.g. being yelled at by a boss or significant other), they may derive a relationship

between the external event and private labeling of self (e.g. “I’m a loser” or “I’m a failure”). The

self is the controlling frame for all other relational frames and understanding the self as context

rather than content or process (See ACT and Self) is a key component of self-knowledge (Hayes,

2005).

Simple equivalence relations can allow people to “re-experience” negative events (e.g.

embarrassment, depression, trauma) (Levin et al., 2012). In the well-known study of Little

Albert, a researcher trained a small child to emit fear responses in the presence of a white rabbit
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and similar stimuli (Watson & Raynor, 1920). The researcher’s objective was to show that fear

was a learned behavior. In the study, the child learned to fear because of the environment similar

to instances with trauma and other emotions. The generality of this instance to other stimuli, led

to narrowing of behavioral repertoires and experiential avoidance because only a limited set of

responses were likely to lead to reduction in aversive stimulation. Although this study was of a

baby with limited language development, the same is true for the manner in which individuals

behave with negative self-rules and apply them to similar stimuli and situations. In RFT, a

relational network is established specifying the various qualities, abilities, or other features of

self.

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Self and Acceptance and Commitment Training
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The self as conceptualized through a behavior analytic framework is critical

to understanding human behavior. As mentioned previously, private events present challenges in

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measurement, however, Hayes, Strosahl, and Wilson (1994) took on the challenge of explaining

the self as a process or phenomenon of human understanding, engaging, and functioning,

originating Acceptance and Commitment Therapy or Training (ACT). ACT is a method of

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investigating private events such as thoughts, feelings, and emotions. It is a clinical approach and

evidence-based form of therapy or training grounded in RFT. ACT assumes that the relations

that a person has formed between stimuli cannot be reversed but the relations with the context

can be changed. The function of private events as establishing operations can be altered to either

evoke or abate certain behaviors. The goal of ACT is to increase psychological flexibility, or

simply put, the ability to enter the present moment more fully and either change or persist in

behavior when doing so serves valued ends.

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ACT rests on a model called the Hexaflex with six core processes separated into two

pillars. The two pillars are commitment and behavior change processes (which includes contact

with the present moment, values, and committed action) and mindfulness and acceptance

processes (which includes self as context, cognitive defusion, and acceptance). ACT can also be

viewed through a Triflex model, which includes all six processes separated into three pillars.

These pillars include the ability to open up (which includes acceptance and defusion), the ability

to be present (which includes contact with the present moment and self-as-context) and the

ability to do what matters (which includes committed actions and values). In either model, no

one process is more important than the other and all processes are meant to work together.

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Just as the processes of reinforcement and motivation seem to be important in human
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functioning these ACT processes are also important. Starting with the behavior change

processes, present moment awareness means giving attention to one’s experience of the present
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moment. This is encouraged in ACT as a means of increasing the probability that a person’s

behavior will be influenced by a broader range of stimuli and contingencies while reducing the

dominance of verbal functions over behavior (Levin et al, 2012). Barriers to present moment
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awareness are fusion with the conceptualized past or the feared future. This fusion with the past

and future can include both pleasant and unpleasant content, such as avoidance of a negative

memory or wishing to recapture a positive experience of the past and fear of a future experience

of wishing for better days ahead.

What a person values means what matters most or what is important to that person.

Values refer to chosen, desired qualities of action that can be “continuously instantiated in

ongoing patterns of behavior and are never completed as a distinct goal” (Levin et al, 2012),.

These verbal constructions function as both formal and motivational augmentals – changes in the
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capacity of events to function as reinforcers or punishers (Zettle & Hayes, 1982), establishing

and enhancing the reinforcing properties of temporally extended patterns of behavior (Levin et

al, 2012), providing a positive reinforcing counterpart to the dominance of aversive control

produced through language processes. Some examples of values could be honesty, freedom and

independence, self-care, self-acceptance, respect, safety and protection, sexuality, etc. (Harris,

2009). Barriers to values include lack of values clarity – this occurs when individuals are not

aware of what is important to them and thus may not engage in behaviors commensurate with

their own values.

Commitment or committed action means taking effective steps guided by values.

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Committed action involves the process of building larger and larger patterns of effective action
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linked to chosen values while breaking ineffective patterns (Levin et al. 2012). Committed action

is arguably the most important behavioral process in ACT, as without behavior change
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dysfunctional patterns of behavior and relating to the external and internal private environment is

likely to continue. Barriers to committed actions include inaction, impulsivity, and experiential

avoidance – these are attempts to avoid unwanted thoughts, memories, physical sensations, and
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other internal experiences even if doing so creates harm over time.

Moving to the mindfulness and acceptance processes, self as context means “pure”

awareness of the thinking self, versus the observing self. Self-as-context refers to a “sense of

self” as a perspective or observer, experientially distinct from the content or the process of

experiences (Levin et al, 2012). The term context refers to the notion that the discrimination of

one’s own behavior as organisms, and thus one’s self (Skinner, 1974), is bound to historical and

current circumstances and not solely to momentary private experiences. Barriers to self as
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context include attachment to the conceptualized self – or discrimination of an individual’s own

behavior in terms of his or her verbally constructed self-descriptions and evaluations.

Defusion means detaching from thoughts, images, sensations, and memories as defining

characteristics of the self. Defusion interventions seek to reduce the literal evaluative functions

of language and therefore reverse the harmful effects of cognitive fusion. This reversal is

accomplished by manipulating the functional contexts that control the transformation of stimulus

functions produced through relational frames. The barrier to defusion is fusion or attachment to

words, concepts, thoughts, memories, attitudes, judgments, and images as representative of self.

Acceptance means “opening up” and making room for unwanted private experiences

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(thoughts, feelings, impulses, urges, images, and sensations) (Harris, 2009). Acceptance
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interventions involve altering the effects of experiential avoidance (primarily the narrowing of

one’s behavioral repertoire) by establishing an alternative context in which difficult private

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events are actively experienced as part of a pattern of valued actions (Levin et al, 2012). Barriers

to acceptance include experiential avoidance.

All six of the ACT processes create psychological flexibility which means being
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present, opening up, and doing what matters. Psychological flexibility is the ability to engage or

disengage in behavior related to one’s chosen values and to contact the present moment as a fully

aware or knowledgeable human being (Harris, 2009). In ACT research, there have been

measures developed for several of the ACT processes. Measures include those that determine

one’s level of rigidity as well as identify their values. However, these measures have not yet been

standardized.

ACT discusses the ubiquity of human suffering, conflict, and self-harm (Levin et al.,

2012) and suggests an avenue for change. ACT has been used for individuals with obsessive and
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compulsive disorder (OCD) (Twohig, Hayes, & Masuda, 2006; Twohig, Hayes, Plumb, Pruitt,

Collins, Hazlett-Stevens, & Woidneck, (2010), with parents of children diagnosed with autism

(Blackledge & Hayes, 2006), for cancer patients with anxiety and depression (Mohabbat-Bahar,

Maleki-Rizi, Akbari, & Moradi-Joo, 2015) but also to promote psychological flexibility within

workplaces and medical institutions (Flaxman & Bond, 2010; Dindo, 2015).

ACT is rooted in functional contextualism which is a philosophy of science which

defines “truth” to mean that an analysis is useful in meeting one’s goals (Levin et al., 2012). It

assumes that behavior itself is never directly manipulated but what is manipulated is the context

of behavior. And causality is viewed as a way of speaking about how to accomplish goals, and

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not as an ontological event, and relative to the goal of functional contextualism, behavior can
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never cause another behavior within the same individual because influence can only be

conclusively demonstrated through manipulation. Thus, despite the fact that behavior and
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context are part of a dynamic interaction and one cannot be defined without the other, only

context can be considered causal in a functional contextual approach (Levin et al., 2012).

Though there are similarities between radical behaviorism and functional contextualism
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such as both philosophies focus on processes of induction, and they acknowledge the importance

of private events, the environment, and consequences as they relate to human behavior (Hayes,

Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013), there are also differences, including that

radical behaviorism focuses on ontological truths while functional contextualism focuses on

pragmatic truths (Levin et al., 2012). Both philosophies are important as they relate to the

behaviors of neurotypically developing adults, the self, and self-knowledge.

Self-Knowledge
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With a behavioral definition of self and the processes of self discussed, a question that

follows may be what does it mean for someone to know themselves or to have “self-

knowledge”? Skinner defined self-knowledge as a special repertoire of human behavior

developed and reinforced by a verbal community like many other behaviors (1953). Self-

knowledge develops out of the appropriate set of conditions which allows the individual to

discriminate their own behaviors or their own private events. In doing so, the verbal community

reinforces what may be deemed “accurate” reports of this discrimination (Skinner, 1953). When

given a reason to observe one’s own overt and covert behaviors, development of a self-

knowledge repertoire is more probable. Skinner states that the absence of a self-knowledge

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repertoire is mainly due to weak stimuli supplied by behavior or lack of reinforcement for self-

observations.
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In a thorough analysis of behavioral research on self-knowledge, Dymond and
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Barnes (1997) recount the behavior analytic literature that sought to describe various measures

and definitions of self-knowledge. One example is through verbal behavior and correspondence

between events that one experiences and verbal reports of those events. The researchers also
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discuss the ability of a person to understand and recognize the variables and stimuli that

influence behavior and the ability to discriminate one’s own images and behaviors as indicators

of self-knowledge. As mentioned previously, reports of private events are shaped and reinforced

by the verbal community. The challenge may be false reporting of private events or

reinforcement of inaccurate statements, however until a more advanced technology is created for

interpretation and verification of correspondence between the private events and verbal reports,

verbal report may serve is an adequate measure for now.

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In addition to these definitions, ACT research discusses self-knowledge as including the

ability to recognize one’s thinking self as different from their observing self, the ability to engage

in perspective taking, the ability to understand one’s values, and the ability to set reasonable and

attainable goals for oneself (Harris, 2009). Skinner (1953) also corroborates this shift to private

events when he speaks about the manipulation of emotional states, stating that one way in which

the individual can know themselves or control their behavior is to manipulate emotional states.

As mentioned earlier, bodily sensations and awareness of them can be viewed as a form

of self-knowledge (includes proprioceptive and interoceptive feedback of the body which is

similar to ACT strategies and exercises of conducting a body scan as part of a mindfulness

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exercise). Proprioception refers to the body’s ability to perceive its own position in space.
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Interoception refers to the awareness of inner body sensations involving sensory processing and

receiving, accessing, and appraising internal signals (Craig, 2009). The verbal community
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supports and reinforces awareness, noticing, and reflection. These ideas are also brought to light

by ACT (e.g. in experiential avoidance, a person might not be aware, therefore present moment

awareness is important for bringing such experiences into awareness via the verbal community
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of the therapist/client relationship).

Self-Care

Another question that may follow with respect to knowing the self is what does it

mean for someone to care for themselves or practice self-care? Caring describes a set of

behaviors aimed at helping and protecting someone. Thus, self-care is a behavioral

repertoire aimed at helping or protecting one’s self and reducing stress (a state of mental or

emotional strain or tension resulting from adverse or very demanding circumstances). It is a set
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of behaviors deliberately initiated to support one’s quality of life or work-life balance (Figley,

2002).

Self-care behaviors can be different for different people. Though self-care may seem self-

explanatory or like an “innate” ability, caring for self may be more challenging than what is

thought. We exist in a culture that moves at a fast pace. The pressure of meeting goals and

requirements of all our responsibilities and roles in a fast-paced environment can add to stress

and lead to burnout. Burnout can be behaviorally defined as a form of ratio-strain – a

disproportion between the amount of work one does, or response effort required versus the

amount of reinforcement received for that work (Cooper et al., 2007). We have access to more

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social circles and events; new technologies are constantly pulling our attention and we are
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bombarded with stimuli that are constantly competing for our attention. Additionally, we seek to

control time rather than our behaviors within the constraints of limited time availability.
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Lack of self-care is an issue for many people, but in particular people who work stressful

jobs. The concept of self-care has been primarily studied in medical and mental health fields

among nurses, doctors, psychotherapists, and clinicians who work with clients who experience
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trauma. In medical and mental health settings research has been conducted on “compassion

fatigue” describing the lack of self-care among medical professionals (Figley, 2002; Killian,

2008) and concluded that the response effort and time spent working with clients who experience

emotional distress, trauma, or behavioral issues can negatively impact the health and well-

being of clinicians. Research has also been conducted on effective methods of self-care for

professionals in the medical and mental health fields (Shapiro et al., 2007), showing that

practicing self-care behaviors can mitigate or allay the impact of highly stressful jobs.

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