Do trials always make us stronger?

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Sometimes I write of success; of hope; of happy endings.

These are notable in part because so much of the time, the families with whom I collaborate are those whose children probably won’t learn to talk or bathe themselves, or whose middle aged children might die in the mental hospital, or whose children might never overcome their meth addiction—or women who, like me, wonder if their infertility might be lifelong.

And by itself, merely “facing a challenge” doesn’t do anything.

In a cruel twist, those facing stressful and often life-long battles also encounter the most unhelpful and banal clichés that range from “not comforting” to insulting or humiliating. They often come from well-meaning people who haven’t walked a mile in the moccasins of those they are trying to help. I’m sure I’ve been guilty of this and that we all will be again.

But who cares about words. The interaction between a speaker and listener, and the actions of people, matter much more. It’s not what I say in a challenge that matters, compared to what I do. I’m reminded of Ogden Lindsley’s quip that “if a dead man can do it, it ain’t behavior”: I guess a dead person can face a problem. But can he solve it?

Maybe I don’t get stronger merely by facing challenges.

In fact, perhaps I become softer, more tender.

I cry more easily.

I empathize more, and longer, with the parents who struggled for 15 years to have a child often to learn that their expensive and long-prayed-for baby has life-threatening and life-long diagnoses.

If I’m not stronger, at least I’m listening more.

And I notice something else a dead person can’t do:

Whatever skills I practice become more fluent.

I listen and get better at listening.

I empathize and gain fluency at showing empathy.

I help, and gain skills in doing helpful things.

I care, and continue to care.

And I share and feel uncomfortable, and become more comfortable at being uncomfortable.

(Sorry, behavior analysts, I’m not sure if that last one was an actual “behavior”. Similarly, I’m sure a dead man could do this one too, but it took me lots of practice to finally become quite skilled at staying calm while having my blood drawn. I would like to stop practicing now, I’m fluent, thank you very much.)

Many parents of my clients with low functioning autism, or the grandparent clients who are raising their great-grandchildren while multiple generations in between are in jail or recovery, tell me that they are tired of being called heroes. That they are simply doing the best they can, all the time, like you or me.

That often they still wish they could do more or do it better.

As I help clients – such as those whose loved ones have dementia – I discover more and more that our trials are universal, although many of them seem so foreign to young people (and to inexperienced behavior analysts in the helping profession).  Lately I have been developing tools that seem so simple, yet also seem helpful to so many different clients, like this Resource_Orienting statement tool for a loved one who is distressed and disoriented.

Whatever tools we use, what matters seems to be to keep going—and to keep holding someone’s hand when it matters.  Granny and PaPa walking.jpg

Part 6 in Trauma-Informed Behavior Analysis: Collaborating like a life depends on it

This article is the 6th post in a series by Dr. Teresa Camille Kolu, BCBA-D, about trauma-informed behavior analysis.

Children on the autism spectrum (or those affected by one of many other developmental challenges) are often less likely to advocate for themselves than their neurotypical peers. This is dangerous, and can mean that if an adult is giving them instructions, they might keep following the instruction – even when it hurts. A dear friend is giving thanks this week for her child’s swift treatment and recovery after he nearly died on a camping trip—when trained team leaders failed to recognize his signs of distress as he followed instructions to continue the hike while he gasped for air.

When our most vulnerable children and adults don’t have a voice, we caregivers and providers must document these risks first, then be ready to look and see (their signs of distress), listen (to their attempts to communicate), and respond, collaborating like someone’s life depends on it (because it just might).

In a few weeks, I will be speaking to parents at an upcoming event around Boulder and Broomfield, Colorado to educate family members and caregivers on what they need to expect from an ethical behavioral provider.

“Did you know”, I said to a mom helping organize this event, “that no one should ever write or enforce an IEP goal that says “Teresa will decrease protesting to 0 levels”? In fact, I would argue that we should not attempt to decrease even “inappropriate protesting” to low rates—at least, not before Teresa can effectively and reliably protest effectively in a way that others understand her.

As we discussed this idea, both mom and I were saddened to remember and revisit the years of similar IEP goals that focused on a target to decrease behavior when there was no meaningful alternative for the child. Regrettably and predictably, Continue reading

Part 5 of Trauma-informed behavior analysis: 6 ways to improve your supervision of trauma-related cases

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This post is Part 5 in the Trauma-informed Behavior Analysis series by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Supervising trauma-related cases? Here are a few tips to help you nurture your team.

  1. Model how to reach out when needed, by reaching out when needed.

Does this seem obvious? Maybe. Do we do it sufficiently? Maybe not. If you want your team to do this with you, show them how you are doing it as well, with your own mentors. Read, obtain consultation, and seek mentorship. I meet rather regularly with a mentor whose experience outweighs mine in some areas (like brain injury) and donate regular time as a mentor for others who need support on issues such as supervision of clients who have been through adverse childhood experiences. It’s easier for me to say to supervisees, “don’t forget to seek ongoing supervision and mentorship when you reach the boundaries of your competence” (e.g., see Professional and Ethical Compliance Code items 1.02-1.03) when they see me doing this at the same time.

  1. Update your team’s FBA practice.

For example, are you documenting the client’s history with respect to aversive experiences, development, and the risks (see Code items 2.09c and 4.05) involved based on their history and behaviors? Are you documenting and fostering robust communication with other professionals involved (see Code items 2.03a-b)? Treating trauma is not the kind of case one does alone (and needs more than a team whose members are all behavior analysts). Cusp Emergence is doing trainings this month for teams who treat cases affected by trauma and we’d love to hear from others on how your FBAs meet the complex needs of this population. The SAFE-T model includes training for supervisors on several components of an ethical and comprehensive trauma-informed behavior assessment.

  1. Understand that clients affected by adverse childhood, medical, feeding or other aversive experiences may differ from your other clients– and that your resulting individualized treatment strategies and recommendations necessarily will differ.

In the next weeks, the “Trauma-informed behavior analysis” series is sharing a couple of articles related to this topic, including “When praise doesn’t work” and “Different types of adverse experiences that change us”. Behavior analysts can document how the trajectories for alternative skill acquisition, or reduction of challenging behaviors, differ depending on their clients’ histories. It can be off-putting to realize that the go-to strategies that worked for most previous clients on your caseload are simply not effective here, but it’s important to know this before you start, because what you don’t know may actually hurt someone! If you think this feels awkward to you as a behavior analyst or teacher, just imagine what this must feel like to a new foster parent of a child with a “reactive attachment” history, when the everyday parenting strategies just make things worse. (For more on this, see #6 in this list.)

  1. Teach your team how to document barriers and risks.

When your staff shares something they overheard a child say, or when your registered behavior technician walks in the house and something fishy is going on, don’t just have her leave with a disturbed feeling… you should already have documented your process for the conditions under which the staff will be required to write it down and discuss it with supervisor and team in a planned way. Over time these documented paths are more important than anyone in the middle of the problem could ever know. For those of us already tasked with reporting MANE (mistreatment, abuse, neglect or exploitation) and honoring our ethics code, it’s important to train staff on what to do with the “not necessarily abuse but definitely inappropriate and risky” situations they see and hear in their line  of work. Don’t leave them to figure out the answers on their own.

  1. Create role maps for key roles on the “trauma triage” team.

This is a tool you can create (an upcoming Resource Wednesday post shares one of ours) that documents the role of each relevant team member. Even if you begin only with the behavior analyst, teacher, and family members on the team, it’s a great start. If the behavior analyst you are supervising is new to trauma, it may be tempting for them to take on too much, to give advice when they should still be collecting data, or to initiate a behavior strategy before you have finished communicating with the social worker about the history of abuse. We can help by using role maps listing roles and responsibilities, making explicit how people can do things within their role that are helpful versus not helpful. Yes, I explicitly spell these out (e.g., if a family is divorced and I work with both sides, I share documents that say how they can help us benefit the child, who remains at the center of the family). “Makes positive statements about mom in front of child” or “writes down concerns with co-parent instead of says them out loud in front of child” are two examples from the recent role map I made for a broken family who was working together for the first time in several years. Grandparents, teachers and anyone who asks “I want to help, but what can do?” also benefit from these role maps. It gives you something to reinforce while you wait, and trust us on this: when there’s nothing specified, people fill in the gaps, often by doing other things that they hope, but that are not necessarily, helpful.

  1. Before you try to help a client affected by trauma, find ways to hear from listen to families who have been there.

There is more on this in an upcoming story, but you can start now by start now researching ways to hear from families in your neighborhood. I learned so much—about what is helpful, and what is simply hurtful and devastating—from volunteering time in various parent support groups, going to county events for adoptive parents, and hearing what foster parents or teachers of children with emotional and behavior disorders are going through. I don’t mean that at that point I was providing any parent support at all, or giving any behavior analytic input: I was just listening to the stories as adoptive or foster parents went round the room sharing from their hearts, their own pasts, and their children’s experiences. The behaviors you hear about will break your heart, and the complex needs of their families may overwhelm you. If you can listen quietly and then you still want to help and not run away, this is a start. Please don’t do this work without this important step. People don’t want to hear from behavior analysts who cannot listen.

I’m listening. Contact me any time.

 

Resource Wednesday: Paradigm Behavior, for family-supportive resources beautifully designed by a friendly BCBA

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At CuspEmergence, we love finding resources or information we can share with our families and community. Imagine our excitement when we discovered this close-to-home resource, an entire website devoted to helping parents become even more amazing at playing, communicating, and connecting with their children! Paradigm Behavior maintains a website and resource library where families can learn, with the support of a Board Certified Behavior Analyst who is a parent herself. Christina posts blogs, resources for supporting play, and online coaching for families interested in developing play skills, language, and more. Paradigm Behavior maintains a well-stocked Playroom, which could teach students and supervisees cutting their teeth in behavior analysts a thing or about connecting with families and using materials in effective ways.

The resources we found were helpful even to seasoned behavior analysts, taking much of the work out of connecting parents with individualized resources that were at once friendly and helpful. We think you’ll love them as much as we do

Check out ParadigmBehavior.com.

Trauma-informed behavior analysis, Part 4: On terms (Is “trauma” behavioral?)

This article is the fourth installment in a series on trauma-informed behavior analysis, by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Is “trauma” a behavioral term?

“Trauma” is a buzzword lately. As several people recently noted on behavior analytic forums, it seems as though schools and other entities are requiring “trauma-informed care” from people tasked with providing behavioral interventions, yet it isn’t clear whether trauma actually presents as anything different than the reinforcement history, or a client’s past, that would be explored routinely in any old behavior assessment.

On a recent facebook post in a behavior analytic group, one person posted, “Trauma”, “trauma-informed”, etc, is [just] the new buzzword to get grant funding and sell product”. Another poster chimed in, “Trauma? What’s the behaviors [sic] of concern? What’s the function?” This seems to imply that if we know the current function of behavior, what more do we need to know? It suggests that the resulting treatment path is likely to be no different than that for a “typically developing child” of the same age and an apparently similar behavioral repertoire.

The implication in the social media posts above seems to be, “what’s the big deal?” In other words, trauma is thought of as some in the behavior analysis community as simply another sexy concept that is meant to sell and sound good, rather than being something critical to appreciate (and to suggest differential treatment based on its presence or absence).

As a behavior analyst who has treated children and adults exposed to serious and adverse childhood experiences, I have come to appreciate that the current function is NOT the only important thing to know before treating someone’s challenging behavior patterns, or helping an adoptive parent cope with challenges a mental health therapist might call “reactive attachment”.

So what’s a BCBA to do? Continue reading

What does hope sound like?

What does hope look like?

The behavioral doctor sat between house calls in her car with amazed tears streaming down her face.

Was this viral story true?bird.jpg

Intuitively, she knew that it must be, for she instantly recognized the chubby little face she saw on the screen. She suddenly recalled the clear little voice asking for “music!”, and a couple of weeks later, “music, please!”. She remembered when his list of words included about five. She recalled singing songs (“Way up in the sky, the little birds fly….”) to a toddler who had needed early intervention desperately.

But the story she read on facebook was also hard to believe, because this young man wrote so confidently and was about to graduate. He also sang so beautifully, as links posted by his mother—and his scholarships to prestigious programs—confirmed. It had been at least 15 years since she saw the toddler’s face, or said “do this” and prompted him to carefully stack one block on top of the other, painstakingly teaching play skills that other children seemed to learn so naturally. At the time she had worked for an early intervention program, providing or supervising up to 7 hours per day of behavior therapy to children whose tantrums often overwhelmed and injured their parents, teachers and skilled therapists—but communicated their wants and needs before they had words. And at the time, she did not know that behavior analysis would become her fulfilling career and that she would go on to study neuroscience and learn how the brain really does change with the hundreds and in some cases, thousands of hours of careful social input that certified behavior analysts are trained to provide.

But this was definitely the same little guy, except he was all grown up. Continue reading

Trauma-Informed Behavior Analysis, Part 3: Is It Ethical For Behavior Analysts to Treat “Trauma”?

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This is Part 3 in a series of how behavior analysts approach “trauma”, by Teresa Camille Kolu, Ph.D., BCBA-D.

Is It Ethical For Behavior Analysts to Treat “Trauma”?

Meaningful answers often depend on asking an appropriate question.

Since this “yes-or-no” question is not the least bit appropriate for many of us to answer “yes” to without more information, let’s start by refining our question.

Under what conditions would it be appropriate for a behavior analyst to treat someone whose behaviors relate to their adverse childhood experiences?

The question above is one way of asking the question, and your team might think of others. It also may help to check out Tuesday’s upcoming article on Behavioral Terminology Related to “Trauma”.

I’ve certainly seen some inappropriate, well-meaning, and harmful treatment of behavior when the children and people involved have been through adverse childhood (or other) experiences.

Part of my concern is that young behavior analysts may have come from a program that did not cover adequately the experimental basis of our field, including schedule effects or concepts like the molecular or molar view of behavior.

I think young behavior analysts who are smart and curious can get these things; they need to have better exposure in their classes (and online course sequences toward certification paths aren’t likely to bring this exposure) or groups (so ask your friendly local or skype article CEU club if you’d like to read an article like this one on the paradigm shift from the molecular to molar view in behavior analysis). This is why a supportive verbal community of reinforcement is so critical for developing behavior analysts (more on that later elsewhere on this site).

(Not sure how to look up pdf’s of articles? An easy way is to first look at the online journal list (for example, for JABA or JEAB) and first enter your search terms, then when you find the article, go to the journal’s archive and click on the issue where the article was published, and download the pdf. This works for all archived JABA and archived JEAB issues through 2012.)

That was fun; let’s get back to the scary stuff: inappropriate, well-meaning, and harmful treatment of behavior.

Sometimes an inexperienced behavior analyst treats only the “local function”, such as treating a behavior in your classroom that seems like it’s related to attention with pure extinction (e.g., without conducting a complete and appropriate functional assessment). This might seem appropriate without more information, but in clients with “trauma backgrounds” or exposure to serious past (or hidden and ongoing) childhood adverse experiences (such as disruptions in primary caregiving and exposure to abuse and neglect), this course of treatment may lead to further harmful escalation, or serious risks and side effects. There are other possibly more appropriate options such as differential reinforcement without extinction, or the preventative schedule approach I mentioned in a previous article. At the least we need to base decisions on better information.

In a classroom where I observed a child who had been through a series of terrible and neglectful situations, when his behavior was placed on attention extinction, he virtually lost all advocacy skills (e.g., stopped manding for help or showing his distress), was being abused by others and never reported it, and started hiding his self-injury which became more and more severe. These were some of the risks involved of using a procedure without evaluating the possible side effects given the child’s repertoire and the reinforcement available for his appropriate skills, and without collaborating with others who had access to the child’s history and current home situation (Compliance Code 2.03b).

The teacher was using the procedure recommended by a behavior analyst, but the BCBA did not know about the child’s history or home life (and did not ask). As I’ve said before, I am NOT asking anyone to stop a function-based approach!- but to demand the information you need to understand the larger context for behavior.

So what’s a behavior analyst to do?

I typically try to think first of ethics (asking, “should I be doing this?”) before diving into strategies (“what should I be doing?”). Here are some ethical considerations:

  1. Is this in my boundary of competence and based on my education, training, and supervised experience?

See Compliance Code 1.02a). If not, it’s a good idea to first seek continuing study, training, supervision and consultation (see Compliance Code 1.02b). I think the skill of reaching out to obtain supervision and mentorship when appropriate (e.g., accepting clients appropriately) may be an important behavior cusp critical to the future repertoires of behavior analysts trying to practice ethically.

  1. I think of ethical behavior analysis as practicing within my boundaries, yet at the same time as growing my boundaries of competence so that next year I will have expanded them and will be able to take a client I said no to this year.

Dr. LeBlanc and colleagues have an article on expanding the consumer base for behavior analytic services that is available for a CEU.

  1. Consider ethics and your own experience and resources carefully, before you begin treating trauma or accepting any kind of trauma-related client.

See 1 and 2 above, and remember not to give advice that stands in for services (e.g., 1.05a). Our responsibility is always to do no harm, and at times the side effects of inappropriate treatment may be riskier than doing nothing (2.09c). It is important to develop a relationship with a mentor who has been there and can assist you to apply new information to an exquisitely sensitive set of problems and clients. If not, arrange for appropriate consultation and referrals (2.03).

  1. All this goes for supervisors too:

Just like we should be careful before we accept a client for treatment, we accept a supervisee who is treating in a sensitive area only after considering our own defined area of competence (5.01). How will we communicate about and report risks (7.02) if we are not experienced enough to recognize and communicate about the risks of our own treatment (2.09)? Agencies may be under particular pressure to accept clients when there is funding, but there are serious risks of doing this too early or without appropriate in-house supervision.

  1. Be prepared for extensive collaboration:

I’ve talked to supervisors who have taken on trauma cases without completing assessments of risks and side effects (2.09c) or collaborating with other therapists the child is concurrently seeing, and this means they are already in danger of not being able to review and appraise effects of other treatments that might impact the goals of the program (2.09d).

Why do you need mentorship, education and experience under supervision first?

This is partly because after you accept a client (e.g., 2.01) whose service needs are consistent with your education and training, experience, resources and policies, your responsibilities are to everyone effected by your behavior analytic services. For example, once I started treating clients affected by trauma, I also found myself treating foster families’ other children to deal with the abuse the affected child talked about, the primary caregiver who used to be on drugs and was trying to demonstrate she could follow a plan and get her children back, and the social workers and other team members who didn’t understand schedule effects and were making placement decisions without data on behavior.

In an upcoming article we discuss some treatment approaches and how we can improve our supervision of BCBA’s treating these serious concerns. But first, next Tuesday covers some behavioral ways of talking about “trauma”. Stay tuned!

And as ever, this information is not a substitute for mentorship or supervision. This is intended for use in supporting behavior analysts to reach out to their own networks and supervisors and mentors, growing their boundaries of competence in an ethical and responsible way.

May we all keep expanding our repertoires.

 

Ethical Friday presents: The power of a Worst Case Scenario

Picture the worst that could happen.

Can you even imagine it?

And if you’re a seasoned therapist or behavior analyst, how do you communicate about this with your students and supervisees, who almost certainly can’t really go there?

If you’re like many of us, you don’t know what you don’t know. Suppose a client wants to gift your staff a gourmet coffee gift card, or a mother wants to step out quickly to get her dry cleaning. “It’s a five minute drive, I’ll just be a second”, she calls, as you work with her child in an upstairs therapy room. “No problem”, you start to call… but your ethics bone starts to tingle. Surely you’re over-reacting. What, if  anything, could go wrong?

When the worst case scenario relates to our vulnerable clients affected by trauma, the consequences may be even more dire– and yet, those who haven’t faced the possibilities may not recognize the dangers.

Should I accept this client in foster care with severe challenging behavior and a history of abuse although I have never treated similar cases? Should my agency supervise our new BCBA to take on a new trauma case (we have funding, after all) when we haven’t experienced this situation?Danger sign

For those of us tasked with supervising and teaching others, or working with families, we can help students, supervisors or parents picture the worst case scenarios so they can better prepare for, predict, and prevent dangerous outcomes. The Compliance code helps give guidance and rules that we follow, but for those of us who have NOT encountered situations that make us keenly aware of the reasons for these, some of the code items may seem “nit-picky” or unreasonable, and may be disregarded in a dangerous way.

To support our own cases and our supervisees where it counts, we must have a wealth of experience, stellar training that exposed us to a variety of worst case outcomes and possibilities and some solutions, or a great imagination- and a few good teaching and documentation tools.

I get a new wake up call every semester I teach ethics students about the origins of Behavior Analysis’ Ethics Code, which was spurred in part by atrocious, life changing and widespread abuses by those doing “behavior modification” in recent decades.

When I ask “what do you think? Could those things ever happen here?”, Continue reading

Trauma-informed behavior analysis, Part 2: Arranging a supportive behavioral environment

(Continued from Part 1 of Trauma-informed behavior analysis series by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)

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Part 2, Engineering Supportive Environments

On arranging the environment

What does it mean to arrange the environment in a preventative way? This means to think about everything someone needs, and how they get it or communicate that they need it. After we consider this piece, we see holes in the behavioral environment.

If these holes go unfilled, the person will likely do whatever they need to do to fill them, often in a way that is ultimately unproductive and painful for themselves or others.

In a way, everyone is doing the best they can, all the time.

So in considering what someone needs in advance, we can find ways to plug in something helpful where it is needed, in a preventative way. This means that before someone needs something, an observant caregiver or friend may recognize the need is coming, and begin to set up the surroundings so that need is being filled. Before someone falls in the well, we fill up the well with concrete and make it so that they cannot fall in — even if they step right on top of it. For example 1 in Part 1, the client who was left alone in the dark is given preventative repertoire building, and taught skills that help her to cope each night with the coming darkness. Her caregivers are taught new repertoires, learning to announce their presence and ask her permission before entering; to problem solve with her instead of forcing the next event on her; and to check in in a preventative way to see if she needs anything, instead of responding with force when something is already going wrong. Eventually, she learns to ask for help before it gets to a crisis, to soothe herself to sleep instead of showing agitation leading to support going to bed, and to problem solve by herself when about to face a known triggering event. Continue reading

Resource Wednesday: How do you document risks?

Many behavior analysis supervisees, students, and even young Board Certified Behavior Analysts (BCBA’s) have not yet obtained proficiency communicating with their clients and agencies about risk assessments, and may even lack the experience or training to use or document them in their own practice. Yet, a risk assessment is required by our Compliance Code (for example, see related items 2.09 c and d, or items 4.06-4.07), and the need for this skill is evident in the Task List (see C-01, C-02, and C-03).

As a consultant and an instructor for a university’s course sequence toward certification in Behavior Analysis, I use the Bailey and Burch text on ethics as a resource both for my students and for my practice. Several editions of this text mention and describe a Risk Assessment Tool which is not only necessary and required, but can also be a powerful decision making tool for teams, supervisors, agencies, and even families. When services are discontinued after barriers to service have been repeatedly encountered, supervisors and the court systems value evidence that the behavior analyst documented and discussed the risks and barriers with a family or team. Also, lives might be saved by considering the short and long-term risks before moving forward with an intervention that is at best, inappropriate, and at worst, dangerous. Risk assessments can facilitate otherwise difficult conversations about risks (or benefits) to a client, family, team, agency, system, or even a consultant’s reputation and credentials.

So what tools do YOU use, and what are those used by your team? Kolu and Winn (2017) presented tools for our work, based on something developed in our consulting practices. First a Risk versus benefit flowchart helps walk a supervisor, team, agency or family through a sequence of questions. Then the Risk Assessment Tool helps keep track of the answers, and can be used to facilitate a discussion with families and teams. When making a tough decision, it helps to ask about the short- and long-term risks of doing “the current option” or doing “something else”, and weigh these against the potential benefits. Should my family pull our child out of a school where he is not really benefiting from education but has immense social interaction opportunities? Should I stay with this employer billing in a confusing and possibly unethical way, or start my own practice? What should I consider when approached by a long-distance supervision client whose client caseload doesn’t really match my skillset?

And as the Compliance Code makes clear, we should be continuously asking, what is the best treatment recommendation, given the possible options, the current environment, resources, and the risks and benefits?

With these questions and more, a risk versus benefit assessment can be extremely informative, helpful, and may even be required. Know the requirements, and then assess, document and communicate about the risks. It might just save your credibility one day when you are called to testify. (We all think it won’t happen to us, until it happens to us.)

Need a tool to document your risk versus benefit results? Download this Risk Assessment Tool and let us know your suggestions or what kinds of decisions you use it for.

Email us if you’d like a word version of the form that you can use to fill in with your team or agency. And if you’d like to share, let us know what YOU use to document risks.