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Cultural Humility: From Clinical Practices to Parent Training

By Angela Nelson, MS, BCBA, Vice President & Executive Director of Clinical Services (Rethink Benefits)

I wonder if I recommended something that wasn’t in line with the family’s values, but they did not want to disagree with me because I was the “expert.”

For decades, clinical professionals aimed to practice cultural competency. That is, they adopted behavior, attitudes and policies to work effectively across cultures.

While this is important in our diverse world to honor issues of rapport, treatment success and equity, Tervalon and Murray-Garcia (1998) discuss how competency implies mastery. Mastery is unattainable when applied to culture, especially if that culture differs from our own. This perception of competency limits learning as it affords a sense of completion. This is problematic when working with a diverse population. Understanding of a culture is never mastered.

So, where do we go from here? Enter cultural humility.

Cultural humility is a term that came on the scene in the late 1990s, as it was applied to physicians’ work with culturally diverse patients. It since has spread to other helping professions. Cultural humility debunks the false perception that one can become an “expert” on each person’s culture with whom we work. Instead, Masters et al. (2019) summarize Drs. Tervalon and Murray-Garcia’s definition as cultural humility as:

“A life-long commitment to self-evaluation and self-critique in an effort to address power imbalances and to advocate for others. The practice of cultural humility helps mitigate implicit bias, promotes empathy, and aids the provider in acknowledging and respecting patients’ individuality. The universality of cultural humility principles puts emphasis on the provider’s need to connect instead of being an expert on the patient’s race, culture, or ethnicity.”

Diversity exists in many forms in our world including race/ethnicity, gender, religion, socioeconomic status, sexual orientation and more. The chances of an exact match in culture between a clinician and client or patient is not reasonable, given the incredible range of variables. However, that should not preclude us from striving to address the inequity that currently exists in the delivery of care.

Davis et al. (2016) found that microaggressions (intentional or unintentional indignities that communicate hostility or insult to a person or group with a harmful psychological impact) committed by a therapist resulted in those therapists being rated less culturally humble, causing a rupture in the therapeutic relationship. Similarly, Owen et al. (2015) found that clients who felt their therapists missed opportunities to discuss cultural experiences reported worse therapy outcomes, and those who rated their therapist as culturally humble reported improved therapy outcomes. The importance of cultural humility in medical appointments and counseling relationships is established, but what does being culturally humble look like in other relationships such as parent education and training?

At Rethink, we work with parents from throughout the United States and around the globe. Participating employers provide these parents – their employees – with free and equal access to Rethink’s video-based lessons to demonstrate how to teach a variety to skills, on-demand webinars, printable materials and other resources. Many families, however, prefer to speak with a professional who specializes in teaching new skills and addressing challenging behaviors (i.e., a graduate-level, board-certified behavior analyst [BCBA]) for personalized support.

Through these consultations, we are able to work individually with families, giving them what they need. Moreover, these consultations are opportunities to practice our cultural humility. Each family presents a unique familial structure that requires consideration by the BCBA.

One example of how cultural humility during parent training is reflected in how a BCBA, or consultant, addresses her own agenda of what skills a child should learn vs. what the family’s goals are is this scenario: to become equal partners. From this point forward, the family can state what they would like to learn based on what is important to them. The consultant remains both a learner and a resource.

As a clinician myself, I can recall early in my career some times where I judged a family for not following through on behavior protocols or skill-building programs I created for them, and for not being what I felt was “invested.” It was only after critical self-reflection that I realized my own biases and attitudes and how that affected my relationship with these families.

I wonder if I recommended something that wasn’t in line with the family’s values, but they did not want to disagree with me because I was the “expert.” Maybe I hadn’t adequately addressed that inherent power imbalance?

At that time, I came into each meeting feeling as though I needed to be the expert and have every answer, because why else would they ask for my help? It was only after I started to elevate parents as experts too, asking questions and encouraging them to tell me when I was wrong, did we start to have a more collaborative and effective relationship.

I have been fortunate to consult for years within schools and homes from my hometown of Los Angeles, to native reservations in New Mexico, Detroit, the islands and interior Alaska, the Bronx, New York, and other places filled with diversity. Now I work with parents all over the world.

While I have seen how humans are far more similar than different, approaches to parenting differ significantly. I cannot detach from my own culture, values and experiences, so practicing cultural humility is a conscious decision I make during every interaction with parents, paired with a post-interaction self-critique with an eye towards improvement for my next interaction. I prioritize being culturally humble to ensure empathy, respect and regard for the people with whom I’m collaborating.

So, where do we go from here?

In addition to welcoming a diverse group of consultants, parent training programs should not just talk about valuing cultural humility but rather engage in behavior that reflects those values. Here are some places to start:

A consultant meets the family of a 9-year-old boy, and she quickly learns that his mother is doing “what seems to be everything” for him – dressing him, cleaning up after him, making him snacks upon request, etc. The consultant thinks she is being helpful by brainstorming ways to help the mother teach her son independence skills and suggests they start teaching basic activities of daily living like dressing.

However, in this family’s culture, it is quite common for the mother to complete these tasks for her son and she says she, “wants to make his life easy and happy.” She does not see this as an area in need of change, compared to the consultant, who is looking at this situation from the lens of her own culture and values (other examples of potential cultural differences include making eye contact, co-sleeping, “acceptable” behavior, mealtime practices and social skills expectations).

While the consultant may be an expert on teaching new skills or reducing challenging behaviors, the family is an expert on their child, culture and their values. The consultant should be inquisitive about what brought the family to explore Rethink’s support, saying, “I’m really looking forward to learning more from you about what brought you to our program. Would you like to share with me what you’re interested in working on together?”

She must also elevate them in the relationship to dispel any power imbalance and encourage them by:

  • Offering training and professional development on cultural humility in the form of professional reading, mentorship, membership to equity and diversity special interest groups and attending related conferences.
  • Encouraging parents to voice concerns about microaggressions or discomfort during interactions with consultants (with a clear and established channel) and humbly take action to honor each concern that is raised.
  • Adding specific questions about cultural humility on surveys for critical, objective feedback. One question Rethink asks participants in a follow-up survey is, “My behavior expert was respectful and considerate of my cultural background, and was open to my perspective when giving suggestions/ strategies with 0 being not at all and 10 being very much.”
  • Conducting ongoing quality checks (i.e., sit in on consultations between consultants and parents with prior, parental consent) and include cultural humility items on feedback/performance rating scales.
  • Encouraging completion of online assessments to uncover implicit biases.
  • Creating coaching tools to directly measure cultural humility (Masters et al., 2019)
  • Establishing critical, self-reflection and self-management as ongoing, professional improvement goals (Wright, 2019).

While it might sound counterintuitive for the “expert” to be a learner in a consultative relationship, think for a moment of the connectedness and trust that could be established when each member of the relationship is empowered. While the efficacy of parent training is predicated on a multitude of factors, prioritizing culturally humble behavior in the relationship is a conscious and empathetic way to set us up for success.


Centers for Disease Control and Prevention. (2020, August 17). Cultural competence in health and human services.

Davis, D.E., DeBlaere, C., Brubaker, K., Owen, J., Jordan, T.A., II, Hook, J.N., & Van Tongeren, D.R. (2016). Microaggressions and perceptions of cultural humility in counseling. Journal of Counseling & Development, 94, 483-493.

Harvard University. Project Implicit.

Masters, C., Robinson, D., Faulkner, S., Patterson, E., McIlraith, T., & Ansari, A. (2019). Addressing biases in patient care with the 5Rs of cultural humility, a clinician coaching tool. Journal of General Internal Medicine, 34(4), 627-630.

Owen, J., Tao, K. W., Drinane, J. M., Hook, J., Davis, D. E., & Kune, N. F. (2016). Client perceptions of therapists’ multicultural orientation: Cultural (missed) opportunities and cultural humility. Professional Psychology: Research and Practice, 47(1), 30–37.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117–125.

Wright, P. I. (2019). Cultural humility in the practice of applied behavior analysis. Behavior Analysis in Practice, 12, 805-809.

Using Technology to Boost Efficiency & Profitability of your Behavioral Health Practice (Webinar)

As one of the most important aspects of a business, it is imperative for business owners to align your technology in order to promote growth in a scalable way.

An often ignored (yet equally important!) follow up to the initial implementation of this technology is monitoring and reacting based on your operations.

Join us as we:

  • Discuss best practices in key business and technology areas that are important to align in Behavioral Health in order to be more successful and more profitable
  • Present case studies of successful business re-alignment
  • Provide ways to identify if your business is out of alignment and what to do about it

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Chad Wiggins is the Director of Business Development at PulseOne. Chad has 25 years’ experience in the IT solutions and technology space. He is a Solutions Architect and enables PulseOne’s clients to maximize business growth with strategic planning, implementing technology plans and ensuring tech resources are aligned with their business goals.

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Paul Freeman is a Managing Partner and the Chief Development Officer at PulseOne. A long-time technology industry professional, Paul brings his over 25 years of experience in business and IT operations best practices to support PulseOne’s business clients. His experience has given him an exceptional view on what it takes to be a successful business and business leader in today’s technology integrated world.

About PulseOne:
For nearly 20 years, PulseOne is a business services company delivering operational support to small and mid-sized companies utilizing our team of technology and results-driven experts.

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Electronic Visit Verification (EVV) for Billing Florida Medicaid - Webinar

Electronic Visit Verification (EVV) for Rethink Providers billing Florida Medicaid (Regions 9, 10 and 11)

In preparation to go live with EVV, please join Rethink’s Electronic Visit Verification via Tellus webinar to learn about Rethink’s EVV capabilities to capture, submit and track claim statuses when billing Florida Medicaid (ACHA BA).

This webinar is aimed to help inform, educate, and train BA providers as we move forward together with EVV and state mandatory compliance.

Not sure what EVV is & Why Is It Important? Check out our EVV article here

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What is Electronic Visit Verification (EVV) & Why is it Important?

If you have any questions regarding your business or individual state requirements, don’t hesitate to reach out to us. We have a dedicated team standing by to help! CLICK HERE

The 21st Century Cures Act is a federal mandate which states that effective January 1, 2021, agencies providing personal care services (PCS) and home health services (HHCS) must have an Electronic Visit Verification (EVV) solution in place.

If they do not adhere, they are at risk of having their Medicaid claims denied. But what is EVV and why is it so important for ABA practitioners, parents and patients?

Continue reading this article to find out more useful information.

What is Electronic Visit Verification (EVV)?

Electronic Visit Verification, or EVV, is a new method used to verify home healthcare visits.

The purpose behind wanting more visibility is to ensure that visits are actually taking place and that patients are truly getting the care they need. Also, that Medicaid is being billed properly.

EVV helps cut down on home visit fraud by practitioners, and ensures that individual patient care is not overlooked.

How Does EVV Work?

EVV is a technology that allows professionals to track the following data:

  • Time service begins and ends
  • Date of service
  • Location of service
  • Name of individual receiving service
  • Name of individual providing service
  • Type of service and billing code

It’s important to note that while location will be recorded at the time of clock in and clock out, it will not be tracked throughout the actual shift.

Most EVV systems use GPS technology to pinpoint when a caregiver arrives at and leaves a location, while others utilize telephone lines.

In these cases, caregivers must call the agency office from a landline that can be traced back.

Benefits of Electronic Visit Verification

While having a basic EVV solution will help meet state legal requirements, there are more benefits for agencies, businesses and behavior analysis services providers.

Those who follow the rules will enjoy streamlined scheduling and billing, and those currently taking advantage of the system will no longer be able to do so.

Time will be saved as processes will be automated and client care will improve.

The 21st Century Cures Act

As stated in the introduction, The 21st Century Cures Act is a federal mandate directing EVV implementation and oversight.

Although the act sets key data points that must be collected and verified, each state will be responsible for creating and enforcing their own systems.

State governments will decide how to gather and report data used by EVV vendors, and whether or not to create additional compliance rules.

The Impact of Medicaid Fraud

Medicaid fraud has been rising sharply over the past few years.

According to The Wall Street Journal, the U.S. government recovered $3.3 billion federal health program fraud tied to individuals and companies in fiscal 2014.

That’s why effective EVV implementation is so important in preventing fraud, but also providing more accurate reimbursement for those who are following the rules.

Rethink Behavioral Health & EVV

Rethink’s practice management suite currently offers Electronic Visit Verification (EVV). This technology gives us the ability to accurately capture visit start and end times, their corresponding GPS location and seamlessly send these visits to the state Medicaid office via the Authorized EVV Aggregator.

Our goal is to help inform, educate, and train behavior analysis service providers as we move forward together with EVV and state mandatory compliance.

If you have any questions on anything in this article or specifically regarding your business or individual state requirements, don’t hesitate to reach out to us.

Enjoying the Holidays During a Pandemic

Rethink experts have compiled this guide for families raising children with learning, social and/or behavioral challenges. We suggest following the recommendations of your public health officials for guidance on holiday gatherings during the COVID-19 pandemic.

As the winter holidays approach, you might be wondering how to balance supporting your child’s learning, social and/or behavior challenges and adapting to the unique circumstances of celebrating during a pandemic. Our team has compiled a list of ideas we think you’ll find helpful.

There are many holidays across cultures, worldwide, during the latter months of the year. This time of year is often filled with fun, family, great food, nostalgic movies, traditions and maybe even presents. This season can also create a wave of stress – a lot of stress. There are more people to see, more events to attend and prepare for, more decorations and distractions, time off from school/work/therapies – the list goes on.

Now with 2020 being in the midst of the COVID-19 pandemic, we may also have to deal with modifications and changes to our usual celebratory routines. This can be hard for some kids (and adults, too!).

Holidays often requires extra preparation, organization and logistical planning in order to keep stress to a minimum. Let’s take a look at some examples of how families can maximize the holiday cheer this year:


Teach valuable skills your child will benefit from having now, so he/she can participate in holiday activities. These include:

  • Motor skills – Practicing spinning a dreidel, crafting, unwrapping and wrapping presents
  • Language skills – Using manners (Please, thank you), following instructions (Don’t touch!)
  • Academic – Budgeting and purchasing presents, baking, counting up on an Advent calendar
  • Social skills – Turn taking, sharing, gift giving, playing games, having a conversation with unfamiliar people
  • Self-help skills – Tolerating winter clothing, trying new foods, sitting at the table
  • Physical distancing – Role playing safe distances
  • Mask wearing – Practicing wearing masks for increased durations of time



  • Set presents out right before opening to reduce temptation
  • Involve your child in decorating
  • Add decorations slowly or scale back what you put out if change is difficult for your child
  • Be mindful of safety (plastic vs. glass ornaments, fake vs. real menorah candles)


  • If you won’t be celebrating in-person with others, consider telling your child sooner rather than later to help him/her cope with a possible upset
  • Consider writing a social story (an illustrated teaching story in first-person) to help your child understand
    how this year’s holidays may be different
  • Get your child involved in brainstorming “distance” holiday games and festivities that might be fun to do over video conference, or select alternative activities to do at home
  • Practice attending religious ceremonies via video conference so when your holiday comes, your child will be more familiar to this format
  • If you plan to attend religious ceremonies in-person, practice going, stake out a spot and plan an escape route if this is not a regular occurrence for your child
  • Practice being around more stimuli (smells, candles, music, etc.)
  • Place a picture of the gift’s recipient instead of name tags on gifts, so your child can participate in gift giving independently if he/she cannot read
  • Wrap up toys/gifts your child already owns if your child is overwhelmed by new/unknown items, so he/she can still participate with others
  • Prepare an event book of past pictures/descriptions to help your child anticipate this year’s festivities, especially if they will look similar
  • Use a visual schedule/calendar to set expectations for things such as when a Christmas tree is coming/going, the dates of Kwanzaa, etc.


  • Work with teachers/therapists to help you prepare and suggest ideas to maintain skills
  • Ask for help from your support network to keep protocols consistent (child-care workers, etc.)
  • Keep exclusive reinforcers handy (items, toys, snacks that are highly motivating but are restricted) for long car rides and behavior expectations during events
  • Use visuals such as sticky notes or a reminder on the refrigerator of what behaviors you are working on with your child and what they are earning, as it’s easier to forget during holiday time


  • Define social expectations for your child if you will be around other people and if there are any rewards associated with appropriate behavior
  • Define social expectations for the caregivers to alleviate confusion and frustration (e.g., take turns between child monitoring/play facilitation vs. family/friend socializing)
  • If mealtime is difficult for your child, give yourself permission to eat ahead of time to avoid food struggles
  • Brief family members of any special requests (pets out of the room, lower the music, need a quiet place for a home base, etc.)
  • Give yourself a pep talk. You are prepared and doing the best you can. This is your holiday, too!


  • Stake out a quiet spot for your child to find retreat, if needed
  • Introduce your child slowly to family/friends
  • Use a concrete visual aid (e.g., an ornament) to signal when it’s someone’s turn to open a gift if impulsivity is a challenge for your child
  • Watch for behavioral precursors, as they may come up more quickly in stressful situations
  • Give tasks/jobs so your child feels included (e.g., helper in the kitchen)
  • Allow staggered gift giving or reserve for later if your child gets overwhelmed
  • Inform unfamiliar/new people of your child’s needs and how to act around them
  • Watch for safety hazards as not all environments or homes are child/baby proofed the way your child is used to at their own home
  • Reserve special one-on-one time for your child to help him/her feel safe
  • Allow breaks or give special roles during eating if your child cannot sit for long periods (e.g., the “roll passer” or the table interviewer)
  • Enjoy yourself!

Overall, this time of year can be sprinkled with stressful scenarios and, while we can’t prevent everything, practicing, preparing and planning ahead can help to make for a more enjoyable holiday season for everyone. We invite you to reflect on some of these tips to see how you can personalize them to your family and the holidays you enjoy. As always, don’t forget to check back into your Rethink account or sign up for you’re a free virtual consultation to further discuss how to make this season a stress-free one for your family. Happy Holidays!


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