This article is Part 10 in an ongoing series about ways that behavior analysts can practice in a “trauma-informed” way. Considering that behavior analysts need to be ready to participate with medical and other providers, this article shares some lessons learned about becoming involved with the medical team. Whether your client is going through trauma or not, it should be helpful. But it’s particularly important for my clients who are being treated in intensive settings for their mental and medical health (often resulting from years of trauma). Be well, Dr. Camille Kolu Ph.D., BCBA-D

One of the ways I like to learn from others is hearing their “lessons learned”. By listening to them share what they have learned and what did or didn’t work, I can hone my own role and be more prepared the next time I enter a similar setting. For many of us, the mental or medical hospital is a new frontier. What can we behavior analysts can do to help in this type of setting?

I think about my role this way: As a behavior analyst, I am not the person’s medical doctor. But we often need to collaborate- and yet most medical professionals are not extremely familiar with collaborating with us. What can I do to support our mutual clients, making their healers’ work more effective?

Here are some ideas that have helped me to integrate into these settings more effectively. In some cases they are lessons I learned when I failed to do something up front that could have made a marked difference later on. In all cases, we have an ethical imperative as behavior analysts to get a medical perspective (or to rule out medical concerns) when there might be a medical component to behaviors that are challenging… but most home and clinic based behavior analysts don’t typically work in the hospital settings.

First, here’s a note to students about your growth path: whenever I get a case I can’t take because of my competence or lack of training in that area, I consider how important it is for me to be able to take that kind of case in the future. Then I engineer my behavioral environment (e.g., make some goals and take some steps toward the training or education or supervision I’ll need in the area) towards taking that kind of case next year. Like many of you, I started my career in autism… but I branched out as soon as possible to mental health settings and collaborating intensively with medical and other treatment providers. You can do it too.

The different kinds of hospitals with which I collaborate on a regular basis include children’s hospitals, basic medical hospitals, and mental hospitals. I also collaborate with medical professionals in the medical wings of group homes, residential centers and regional centers. This affords rich experiences with and learning from medical professionals… from nurses to physicians to all kinds of medical team members and specialty service providers working in a medical setting. (Some behavior analysts are already connected to hospitals via their everyday work, such as BCBA/psychologists in children’s units, or researching behavior analysts who are involved in behavioral pharmacology, drug or offender treatment. But for many of us, this collaboration is rather new).

Reaching out to medical professionals has almost always been a helpful thing to do on my cases. The following notes share a couple of basic “DO” suggestions, as well as some strategies that have been helpful in the hospital setting. By the way, this is related to trauma for my clients with ongoing life threatening illnesses, those who have been through medical trauma, and those who are being treated for a medical or mental health issue and have also lived through aversive experiences.

DO: insure you already have the guardian permission well established in writing. I typically do this myself although the agency may have their own document. You need to insure you honor your agreement (including whether it covers your sharing information with the medical professional or just receiving it).

DO: provide a letter of introduction briefly explaining who you are, your credentials and how you work, including the “ask” (what you need from them; how they can help your mutual client). In some cases one contact is all I need, such as interviewing or obtaining records from a medical professional to see if medical involvement is needed or if a medical issues has been ruled out, is being treated, or has been resolved. But in the other more long term cases, the strategies below have been helpful.

And for all you collaborating providers out there, some of the strategies below are similar for other types of agencies such as educational providers and schools.

1. Systems support strategy: Research what the hospital or medical agency’s policies say about behaviors that lead to restrictive environments and strategies.

Okay, BCBAs, why is this important? First, it’s professional: how can you make recommendations without knowing what they already do when they are managing behavior? You need to know what worked (or didn’t work in the past). Second, it’s practical: if you miss this step, you may be in the position of giving recommendations to a team of nurses who listen resolutely to your assessment and plan and shake their heads as you walk out, knowing full well they could never adopt your strategies because it goes against their company policy. Third, it’s not personal: BCBAs who interview nurses about what they do when behavior occurs may think it’s a training or motivation issue (why are the nurses doing x when clearly it’s making the behavior worse, we wonder?) when it’s simply a matter of rules and policies. Maybe it’s even a practical skill that functions as a “behavioral cusp” for you as a behavior analyst, to learn how to assess the environment and build on data that is hidden and right there for the taking.

A case example: In one case, I was still in the “research phase” of the assessment for a client with self harm and behaviors that hurt others, when I learned that her hospital’s restraint policy was to respond to “challenging behavior” by first offering the client all manner of items and interactions that were really pleasant and preferred, in an effort to “calm them down and de-escalate the behavior”: if this didn’t work they were to move to physical and mechanical restraint. The client was never offered these things before the client’s behavior escalated, so she reliably “escalated” to produce these wonderful things (like massages and music”) when there was nothing stimulating going on in her environment. Because I learned this by reading the hospital’s policies, I was able to be much more empathetic with nurses (and educated when I talked with administrators), and simply knowing this policy ahead of time made my assessment make much more sense and put behavior into “context”. (We might have thought this was a training issue but it was actually a systems level policy issue that required some administrator education and changed the lives of many patients!)

2. Team strategy: Don’t create more work for them. Please value their time. Value the work they ALREADY do. Build on their strengths and start by analyzing what data they already produce regularly.

This one can be a real eye-opener, yet we often go right to giving our own data collection forms which staff may find extremely cumbersome. What they don’t often tell us is that “this is redundant; we have already been taking regular staff or nursing records on most of this” or “the hospital already keeps that kind of data if you just ask the right person”!

Doing this ahead of time gives you something really valuable on both sides… a road toward staff buy-in. I think there are few things worse than doing all the work of data collection and having no one care or look at it, and nothing more frustrating than being asked to do something that seems like “extra work” when you already have something that could yield useful information.

A case example: A behavior analyst was called to record data on “behaviors for decrease” and “behaviors for increase” to start a functional assessment and made several different versions of forms that attempted to document the frequency and distribution of behaviors during a client’s day. But the staff were “resistant” to data collection and the behavior analyst problem solved, took hours retooling the forms, and meeting with staff trying to convince them to “take data”. Meanwhile, several staff already had job descriptions that involved their keeping logs of any contact they had with the patient, and what they had observed during these interactions. Any behavioral incident was already put into a staff computer and kept for the company’s internal records. Medication and medical records were readily available from yet another department, and when these were cross-analyzed, physical and attention functions of behavior were immediately evident in the data, which was rich and extensive and available for the asking… and required nothing “extra” from staff. The behavior analyst had the previous three months documentation for “schedules of reinforcement for staff attention” right at her fingertips had she asked.

3. Team and system strategy: Find out what they value about what you do, and give them something they can all benefit from even if they don’t work 1:1 with the client you are there to support.

For example, when I work with hospitals and residential agencies I can give them a little training or some handout about what they have found most helpful or interesting. In my work with dementia, sometimes I use the preventative work I have done on “how to use preventative behavior strategies in ways that might help everyone with dementia”. This doesn’t tell them what to do in an individual case to respond to behaviors, which would be inappropriate of me to do outside an individual agreement and assessment. But preventative strategies such as checking regularly with someone to see what they need, or helpful ways to phrase offers to help, might be appropriate strategies that could be done with a few minor schedule tweaks. If appropriate I share this information with the agency’s trainer and give them more resources so that they can pursue appropriate or more individualized continuing education in the topic.

Behavior analysts, what do YOU do in a treatment setting like this? Share your tips with Cusp Emergence or let us know if these are helpful. Next week out trauma-informed behavior analysis series goes to school… find out more in our next article about treating trauma collaboratively with educators!