Category Archives: ethics

What happens when a BCBA-D gets lessons from domestic violence specialists? 6 strategies to take to heart

Featured

Posted by in adults, BABA, Behavior Analysis, boundaries of competence, collaboration, Community, conferences, continuing education, ethics, TI-ABA, TIABA, TIBA, trauma, trauma-informed behavior analysis

≈ 1 Comment

Tags

, , , ,

(An article in the TIBA series by Dr. Teresa Camille Kolu BCBA-D)

One day this spring, Dr. Camille of Cusp Emergence sat down to answer a few questions, and learn a LOT, from Enasha Anglade of LaughLoveLive Again. (You can learn more about Enasha and her work on Episode 87 of the Behaviour Speak Podcast!) Enasha and her fellow researcher and BCBA, Stephanie, talked with Camille about how Enasha’s company and work applies behavior analysis to supporting individuals affected by domestic violence. (And did we mention this dynamic duo will be presenting at BABA this weekend?! Go find them if you’re there!) We also discussed some of the barriers people face in this special context. Not all barriers can be solved with behavior analysis, of course, but there are many things we can do to insure we are minimizing the ones we know about, always staying open to learn about the client’s experience and special context. Each of the headers below reflects an important point heard from Enasha and Stephanie and some thoughts from a trauma-sensitive and behavior analytic perspective.

  1. First, be safe.

Interested in getting involved in working with this population? First things first: it’s really important to be safe for someone. This may seem like a no-brainer. In fact, providing a safe starting place for your therapy is where all trauma-informed support begins, even if (and especially when) your therapy is not treating the trauma itself, but solving problems or building skills or meeting needs related to it. However, there are so many ways behavior analysts violate this number one rule. We might do it unintentionally, such as when we go right to changing behavior instead of listening to a person’s experience and what they truly need first. While there are many trauma-informed resources out there on establishing safety and trust, you can also check out a course on building trauma-sensitive environments (starting with safety), or read a behavior analyst’s discussion on safety in Rajaraman et al.’s 2022 paper on trauma-informed applications of behavior analysis. But don’t skip asking the person how they feel safe and whether there are things you are doing or saying that contribute to their safety or their experience of danger. That’s right- behavior analysts can inadverdently present danger signals to our clients in many ways. When someone is in the middle of a dangerous situation, they are in survival mode and not ready to learn. We don’t want to trigger this for a client and we don’t want to make worse a situation that already exists for them. Being safe (and making sure our presence and therapeutic environment are safe) is not about helping clients avoid all aversive, challenging, or difficult circumstances. Our clients (especially in this context of domestic survivors) are already going through one of the difficult things in their lives. Coming for help and walking out of horrible situations may be even harder than what they’ve been through before… it will be unfamiliar, may be incredibly risky, and may occur at great personal cost to them. What they’re doing is brave. They’re already doing the hard thing. This is about taking their hand and really listening to what they’re going through.

2. Don’t be afraid to go there… but secure support for yourself so your client does not have to do the work for you

Speaking of listening to what they’re going through, behavior analysts can be bad at listening. Does that sound strange? Behavior analysts are great at observing, typically by nature and training… but we can learn to be better listeners, too. And it’s CRUCIAL in this work. Enasha notes that we are often afraid to be personal, to “go there” with our clients. For behavior analysts in the trenches of severe challenging behavior, we’ve often gotten our hands dirty, literally. But to understand our clients coming from domestic violence, being a witness to their story can be meaningful. Listen to your client. Listen long enough to hear. Listen enough to learn what they could benefit from, too. She may need a counselor recommendation, a connection to somewhere she can forge a meaningful relationship, or a tool that you can’t provide (but that someone you know, could). Their daughter may need help for something you don’t treat. Most important, listen to help your client, not just to facilitate your client’s progress with your program.

Related to “going there” with your client, make sure you are not a burden on THEM. If their issues trigger you, your session with them is not the time to discuss that. Of course, there’s nuance involved in learning to listen to someone, so it would be helpful to do any or all of these suggestions: secure your own therapist to go to if you are troubled; be prepared by using specific ACT and mindfulness techniques that keep you able to use your flexibility skills; help your staff debrief with pre-planned supportive interactions after difficult client visits; learn more about motivational interviewing (for a constructional approach from a behavioral perspective see Goldiamond’s constructional interview); and provide training for you and your staff from a trauma expert outside behavior analysis to answer questions about how to support someone disclosing difficult material).

3. Value relationship over rapport, but in the right way.  

Your program isn’t everything. Behavior analysis doesn’t solve every problem (despite Skinner’s ideas about saving the world and articles by more contemporary well-intentioned behavior analysts interested in supporting human beings). But your relationship with your client might matter more than you think. And I’m using the word “relationship” instead of “rapport” on purpose. (This section could also be titled, “De-centering us, and behavior analysis, while putting a higher priority on that person and what they need”.)

Of course, if we were talking about real rapport, in the way the layperson uses the term rapport, we’d be talking about the same thing as relationship. The word rapport just means “a close and harmonious relationship in which the people or groups concerned understand each other’s feelings or ideas and communicate well”. But in behavior analysis, the word rapport typically connotes a more transactional process, one used as a procedure as a means to an end. Ultimately, many behavior analysts view rapport as a process one includes in the beginning of sessions or relationships with clients so that clients will be more likely to approach the instructor, and so that the instructor can deliver instructions, reinforcers and other environmental stimuli that encourage the client to change their behavior in specific ways the team has defined and prioritized.

Relationship viewed as an end is different. It has benefits beyond the program. It validates the person and prioritizes their needs. You might think of the way that with a relationship between two people who care about each other, we say goodbye when we’re done. We don’t just transfer off the case without letting the family know because we got a new job, or our hours were cut. However, we’re also not suggesting behavior analysts engage in dual relationships with our clients (an unethical and unhelpful practice to be sure!) What we’re really saying is to value the person over momentary instructional control, and treat them… well, like a person. We still need to be careful, and cautious, to preserve the integrity of precious boundaries. In other words, you are still not going to show up as your client’s “friend”, and you need to teach them, lovingly, how this will work in the beginning of your therapeutic relationship with them. You care about them, and you care enough to support them with their goals. That may include finding friends, or engineering environments that facilitate their making friends, but that’s not you; you’re the therapist. You can still be a good listener, care about your person, and support them without being their friend.

We can program toward the end the entire time, so that there is no disruptive surprise for the client at the ending of the relationship. I like to think about this as fading out interactions to a very low rate that is tolerable, and with programming additional sources of reinforcement for the client. Being the only person your client can trust wouldn’t be helpful; what if you were to have a car accident, move away, or have to reduce your hours? All those things happen, but if you plan from the beginning, you can insure they happen in more therapeutic ways. Be really careful to use ethics code guidelines on transferring cases, especially when you are working with someone in a sensitive and vulnerable situation like those surviving domestic violence.

4. Accept this: any behavior can be influenced both by its consequences in the moment, AND the relevant context and history.

When loud voices in the room ask “what does history have to do with behavior? Shouldn’t we just treat the function that’s controlling it now?”, it can be tempting for vulnerable behavior analysts to question themselves. Should I even be taking a trauma-sensitive approach? Should I take this person’s history into account at all? If it’s just paying off for them in the attention it produces, and we technically know about methods to turn behavior on and off using procedures based on consequences and arranging stimulus control conditions, what does it really matter?

Actually—in terms of bringing up trauma, or changing goals based on it—the answer may vary depending on what the client needs! CuspEmergence doesn’t recommend taking a trauma-informed approach when clients don’t need it. But those going through domestic violence all have been through trauma, by definition. As Rajaraman et al. (2022) states, “Responses to trauma may indeed vary from person to person; however, ACEs are well documented, and a preventative TIC approach would acknowledge their potential impact”.

We recommend behavior analysts working with survivors of trauma be intimately acquainted with the ways trauma relates to behavior, to medical needs, to subsequent challenges and needs, and to the barriers people face in moving on to healing circumstances. (See the sections nearer the end of this article for educating your team if that’s not your forte). And yes, behavior can be influenced by BOTH history (such as the trauma-related factors that were present when someone began to use behaviors that are now difficult for them and they want to change, even if those behaviors are NOW maintained by other environmental factors).

Because behavior is at any moment a function of the dynamic interaction between the local and historical context, it is possible that the intervention strategies identified during the functional assessment phase as “likely to be effective’ will need some modification when it is actually time to intervene. As Stephanie notes, clients affected by domestic violence may face unpredictable and changing needs. The needs of the client demand that the analyst be flexible and sensitive to the contingencies and challenges our client faces. We should be especially focused on tracking the ways we might be contributing (perhaps unintentionally) to coercive cycles of interaction for our client, perhaps hindering their growth by playing in to a power differential or offering choices using an architecture that WE don’t perceive as, but the CLIENT experiences, as coercive.

5. Identify the basic training your team will need. What are the most essential and meaningful training components your staff will need? Who provides that training, and how can you value it at the levels of culture, group, and individual?

What happens when most of the team cannot relate to the particular difficulties with which a client is struggling? They might recommend changes that are not feasible to the client; they might miss danger signals the client is sending based on what is happening around the client (and miss an opportunity to prevent harm); they might take personally or misunderstand the challenges a client is having and miss crucial chances to intervene appropriately; they might cause harm by actions intended to help; and so much more.

One team we know used to have a person on staff who provided this training because she had been through it, but her caseload is now too big for her to spend time with each new staff person. As the team grew, the personalized approach they were known for was eroded and eventually, the services they provided looked like most other agencies, and they were no longer meeting the individual needs of client families. However, they didn’t know it until they received feedback, because nothing had been intentionally changed; it was simply a product of drift that happened with the welcomed growth going on.

So one solution for teams with similar paths is to prioritize providing training from a reputable and experienced source, and doing that both routinely and in a way that continues to answer questions the new team members will have as they gain their own experiences and put their previous knowledge into their new context. In a subfield like domestic violence, this training needs to come from someone either outside of behavior analysis, or from someone whose training, expertise, experience and culture strongly intersects with that of the clients and their needs. If this person is not on staff, it is essential to secure regular training, as well as embedding this as a priority into the agency’s mission, core processes, values at work, and interacting with clients. Staff should not have to ask for designated and regular times they will be paid to access and discuss and apply the training (and receive appropriate feedback from someone equally experienced and trained).

6. Identify the most important kinds of support your clients will need that you cannot or do not provide. What kind of support is needed, who else provides it, and what would you like to be doing in 5 years if you removed barriers related to this support?

The first part (who else provides this?) is a logistics question. Prioritize finding those answers right NOW. If most of your clients receive behavioral support from you, but also need to be able to access certain other resources to survive, find out all about those resources and who provides them.

The idea is that you can position your agency in the middle of a network to which you can connect your clients. You do not want them struggling, alone, with something that could make or break their ability to come back to access your services or to implement them. We can start small, beginning with very simple connections you provide your client, such as a list of websites, phone numbers and connection names for partner agencies in your area that meet big needs (and funding options for those needs).

The second part (what would you be doing in 5 years if you removed obstacles?) takes more planning, but might make sense strategically depending on your clientele and their challenges. Some of the solutions could include creating a part- or full-time position of Resource Coordinator, hiring a social worker, or forging a strategic partnership with someone who fills this role for other companies and who knows your area well and can devote time to your own clients on a weekly or regular basis that makes sense for your client volume.

Do you do this work yourself? Contact us and add your essential strategies. Want to learn more? Find Enasha and Stephanie at BABA, listen to the podcast (Ben is in Detroit right now documenting BABA 2023!), follow ACES and ABA groups on social media, send us a comment and leave us your email below, or take a course on trauma sensitivity. We hope to hear from you soon!

Go back

Your message has been sent

New 4h course: Autism, TIBA and Ethics

02 Wednesday Feb 2022

Posted by in Autism, BACB CEU, Behavior Analysis, behavior cusp, CEU, collaboration, continuing education, contraindicated procedures, Cusp Emergence University, CuspEmergenceUniversity, ethics, Fetal Alcohol Spectrum Disorders, Uncategorized

≈ Leave a comment

Tags

, , , , ,

Last time I wrote, I shared some ideas about this intersection. Today, the new course is up! Before you go check it out (and claim your February 2022 coupon for 20% off by typing ASD2022)– during the introductory month of the course)- learn why I’m so passionate about screening for trauma in a population so many behavior analysts have been working with (for some, virtually their entire professional lives).

Have you ever worked with someone in pain? How do we know if they’re currently hurting, whether it’s because they are sick, it’s related to interventions we chose, or from experiences we reminded them of? How would we know if that was the case? Did that person cower, freeze, or grimace? Did they flinch, close their eyes, seem to “zone out”? Perhaps someone has run away, played repetitively with the toys they had, or fallen asleep at school? Sometimes, respondent behaviors may be giveaways that people are experiencing fear or in pain, but successful avoidance behavior can hide that pain. Other times people have been through experiences making them more likely to use aggression or property destruction. In the least, we should consider whether our interventions cause harm. This harm could include causing our clients distress or pain, exposing someone to additional risks, detracting from their quality of life, failing to program in sustainable ways that transfer to the maintaining environment, and so much more.

A new training is up on Cusp.University on the intersection of autism, trauma informed behavior analysis, and ethics. By the time we near the end, we have discussed and revisited the idea of contra-indicated procedures. Given that lists exist for diagnoses of autism alone, why isn’t there a list of best practices appropriate for clientele meeting diagnostic criteria for autism who also come to therapy with trauma histories? Why is it so difficult to find articles suggesting best treatment paths for individuals with both autism and trauma related experiences in the literature? In behavior analysis, answers to these questions may be related to our field, its historical publishing practices, and the ethical and pragmatic need to individualize procedures for each client.

In terms of publishing practices, a panelist in ABAI’s “Exploring Publication Bias in Behavior Analytic Research” (which included Galizio, Travers, and Ringdahl, 2021) stated,

“No intervention is guaranteed to work for every individual, every time, in every context.”

They suggested that authors writing about their research should include more detailed descriptions of the conditions under which successful implementation of the intervention occurred.

When we screen for trauma related or aversive historical situations and stimuli, we often learn things that

  • help us prioritize treatment,
  • document risks for certain procedures,
  • avoid or prioritize certain stimuli,
  • detect environmental conditions that are acting as motivational operations and conditioned MOs,
  • and ultimately, perhaps minimize harm to our client.

Screening for trauma can help to identify individuals with prior risk factors who are at risk for experiencing additional adverse events and aversive conditioning. Attendees learn in chapter 1 some facts about how being autistic is to be at increased risk for trauma, bullying, abuse, increased likelihood of experiencing foster care—and in chapter 3, learn about the higher rates of experiencing restraint, seclusion and being excluded from school.

But another effect of screening – one that should affect all behavior analysts—could be an increased awareness of the fact that behavior analytic procedures are being used all the time for this population at the intersection of autism and trauma. Perhaps the least we can do is to begin doing behavior analysis with people instead of to people, and to be transparent, inviting, and open in looking at options—and their likelihood of causing harm either now in the future.

Let’s look at this juxtaposition: we have a great ethical responsibility to do no harm, but also an ability to cause great harm. With using any behavioral procedure there comes a risk that we may do just that. This is especially true when we don’t have literature evidence that a given intervention is appropriate and effective for the person’s needs given their history and current situation. Perhaps they don’t actually need behavior analysis seeking to change their behavior as much as they need a roof, a meal, a bus pass, a blender, a respite provider, a ride to the doctor, a coat, a medication, a trip to the dentist… the list could go on and on. So clearly the first step is to see what the person needs.

When designing an individualized behavior support plan, two things are important to consider:

(1) the risks and benefits for the client themselves, given their needs, values, environment, etc., (e.g., the long- and short-term outcomes of procedures and decisions, and

(2) evidence the procedure is appropriate for our client.

In terms of evidence, when considering decisions in context of the literature, few studies provide sufficient detail in characteristics of the participants. So it is difficult to tell, reminds the panel, which characteristics were present for study participants received successful or unsuccessful interventions. Thus we can’t really tell how many of the massive number of papers on treating behaviors in autism, also apply and were conducted with individuals with autism who also had a trauma background. But statistics suggest many of them must have. In the science of behavior analysis, each subject’s behavior is its own control, so if we control our conditions and try to measure well, we may reveal additional elements of historical and current behavioral environments that exert contextual and stimulus control on the client’s behavior- and that change their needs. At times, historical aversive conditioning experiences may have contributed changes making it painful or inappropriate for clients to experience certain interventions. As we discuss in the new training, some of those conditioning experiences may even have occurred during and as part of behavioral treatment.

We can’t know for sure what our clients have been through. But when owe it to them to honor those experiences if they are comfortable sharing them.

Here are some of the things you’ll learn.

Course Objectives: 

1. List connections between autism and trauma in the research 

2. State different kinds or examples of trauma that may affect individuals with autism 

3. State supportive ways to ask about trauma histories

4. Select examples of how medical history can be related to trauma

5. State examples of repertoires beneficial for practitioners who serve clients affected by both autism and trauma

Ready to learn more? The new training offers hints from Dr. Kolu on how we begin the conversation about informed consent and screening for trauma, why assent is so important, how trauma and autism might intersect with medical needs affecting our clients, and more. And all the resources are available as free content in the preview section, so go grab that now! See you at a conference soon or find us online. And thank you for listening!

Self-paced SAFE-T Assessment Training is here!

16 Tuesday Feb 2021

Posted by in adults, Autism, BACB CEU, Behavior Analysis, behavior cusp, Behavioral Cusp, CEU, children, collaboration, Community, continuing education, contraindicated procedures, Cusp Emergence University, CuspEmergenceUniversity, Education, ethics, mental health, resources, risk analysis, risk assessment, risk versus benefit analysis, supervision, teaching ethics, TI-ABA, TIABA, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

≈ Leave a comment

Tags

, , , , , , , , , , , , , , , , ,

It’s finally here! We have learned so much from workshop attendees, trainees and supervisees in this area over the past several years, and appreciate the attendance, feedback and support of everyone who has taken the training or used a version of the SAFE-T Assessment. Coming on Monday, the booklet and training for assessing trauma-related factors affecting our clients of behavioral services, are available ONLINE as a self-paced course. This course provides a download of the new and expanded SAFE-T Checklist booklet, which contains several tools enabling the screening and documentation of over 200 trauma-related factors, and a Risks and Needs form to help teams understand (and document) how these factors confer risks (and converge in risk factors that must be solved or mitigated to protect our clients, teams, and ourselves). The booklet contains an extensive reference section and team supportive tools as you use your new knowledge to better align your team’s skillset with the Ethics Code, and the individualized needs of behavior services clients after trauma.

Several of our behavior analytic and collaborator clients across institutions, educational facilities and private companies clients have shared that learning to assess risk factors related to trauma, and to apply this information to their teams’ FBAs and risk mitigation plans, took their skillset to the next level – essentially affording them an opportunity to acquire an important behavioral cusp for their teams.

Some new components of the booklet include:

  • An optional buffer/ resilience score to assess whether protective environmental and therapeutic components of a client’s plan are in place (to understand some ways that trauma gives rise to medical and behavioral challenges and some buffering factors that can help, please see the book or scholarly articles by Dr. Nadine Burke Harris (e.g., Oh D.L. et al. 2018), who is the Presidential Scholar for 2021’s upcoming Association for Behavior Analysis International’s conference. She will address the critical topic of breaking the intergenerational cycle of adversity, and screening for ACES (adverse childhood experiences).
  • Table of potentially contraindicated procedures (cross referenced with items and risk clusters assessed in the Risks and Needs form)
  • Information about over 50 risk clusters (groups of related risks in the 6 assessed sections of the SAFE-T Assessment)
  • Cross-reference tables showing, for each item we screen for, the location(s) in the SAFE-T Checklist
  • Infographic on components of a trauma-informed FBA
  • Brief templates for Risk Versus Benefit Analysis and Risk Mitigation Planning
  • The IPASS (Inventory of Potential Aversive Stimuli and Setting Events) tool and instructions
  • References (organized by topics) covering over 40 areas or topics of literature related to trauma (including relationships of ACES to medical problems, ACT and intellectual disability, ACT and anxiety, foster care and adoption, the relationship of abuse to pain, drug use and trauma, and much more).

Time required: The course includes about 4.5 hours of video content in 12 lessons, each followed by a brief quiz.

Price (includes 4.5 CEU course and SAFE-T Assessment booklet download): $189.99

For $20 off through the end of February, use the coupon code “SAFET20”.

To register: cusp.university

Homebound and Vulnerable: What will you do to prevent abuse and neglect?

24 Tuesday Mar 2020

Posted by in adults, Autism, Behavior Analysis, boundaries of competence, children, Community, coronavirus, Covid-19, Early Intervention, Education, Education and Trauma-Informed Behavior Analysis, ethics, mental health, Uncategorized

≈ Leave a comment

Tags

, , , , , , , ,

This is the 19th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. Start by becoming informed; then please read to the end if you’re interested in taking steps with your organization to support therapists and teachers to continue to fulfill their roles as mandatory reporters.

Child abuse, elder abuse, domestic violence, and abuse of people with intellectual disabilities is going on all around you. It may have just become simultaneously more prevalent, invisible, and insidious.

For example, in some areas, there has been a marked decrease in calls to the hotlines that typically lead to welfare checks for vulnerable people in their homes to insure that families have resources they need, children are not being abused or neglected, and appropriate actions can be taken if they are. (See this story from Colorado reporting a drop in calls the 9th and 10th of March as schools began to close).

Across the nation, different states are reporting similar decreases in calls but also a spike in the number of serious child abuse hospitalizations and even deaths.

Reasons for this disturbing increase are numerous. Little annoyances become big ones when there is no possibility of a break and both mental health (e.g., patience) and physical (e.g., food and sleep) resources are running thin. Even a normal battle on whether your kid will eat the peanut butter sandwich becomes a crisis when you’re trying to feed several people a balanced diet with whatever dwindling foodstuff you still have in the cabinet, while money (and outside trips) become scarce.

For many families, the struggle is not only real but getting uglier by the day, by each hour the kids are home from school.

There is conflicting advice, some of it really unhelpful, yet most of it well-intentioned. (I read a recent article about how we should just give in and let kids watch endless videos during this unprecedented time; but for many children, a huge increase in access to media may be accompanied by major behavior challenges (and even injurious and aggressive behavior) when parents try to have them turn it off for meals or bed. Research shows increased screen time can cause impulsivity, hyperactivity, and inattentiveness,

all of which are even more difficult to deal with when you’re cooped up. Of course, you need solutions, and the quick fix is even more appealing right now.

And there are major barriers to resources. Some have said this crisis is leveling the playing field, but really, it’s revealing discrepancies.  

Being quarantined at home doesn’t hurt that much when there’s plenty of food, you already know how to navigate technology to work from a home office, and there is room and time to get away from housemates or family members for a little while.

Being at home with other people who normally require 7 to 9 hours of behavior support and school-provided structure, let alone meals, while you work to make ends meet—that is another story altogether.

So there are the struggles to which we can all relate, and then there is the reality of jumping into these struggles with no help, no end in sight: There is the reality of suddenly not being able to be by oneself for even a minute, and not knowing when it will end; there are children whining or crying (or hurting themselves while other things need their caregiver’s attention; there is behavior, so much behavior, that a parent doesn’t know how to handle and is made worse by a lack of structure, suddenly upended routines, and for some, the complete loss of safety figures.  At the same time, there are abusive people who are now alone with their victims for the next few weeks.

Maintaining a safe environment for a child depends on several behavioral and environmental factors. Right now, those factors are not all present. Instead, we have

-Caregiver behaviors that are really important to keep people safe, but may not be FLUENT (such as giving effective instructions to a child, creating a schedule for several people, or responding to unsafe behavior that you usually don’t have to respond to)

-Caregivers that may physically present, but not AVAILABLE (e.g., an adult who can provide continuous, adequate supervision to every single member of the household who needs it)

-The presence of new circumstances creating unsafe environments (such as having 3 children with special needs home at the same time, for hours and days on end, and without the things (therapies, bus drivers, respite workers, social outings and educational time) that typically provide structure and relief)

-The additional presence of huge stressors (the unending flow of news about the virus; the dwindling of food and resources; the loss of jobs)

-Competing, sometimes incompatible, needs (like people home from work who need quiet to make money but who also have to provide constant caregiving and supervision; or people who have intellectual and other disabilities and are without their scheduled programs, events, therapies, social opportunities)  

-Therapists and teachers who are working from home or not at all, but who normally document and relay evidence that a child or adult may be being abused, mistreated or neglected

These factors and more combine to produce

-The occasion for more abuse or neglect to occur

-Decreased opportunities for abuse to be reported

-Emotional and physical needs that may make the outcomes of a child being quiet or following directions suddenly much more important or reinforcing, whatever the cost

So, my therapist, day program provider, and educational staff friends- how will you add and document safety checks for all your clients on a reliable schedule to take the place of “having eyes on” the client in your clinic, their home, or your school or program?

There are no hard and fast answers. For instance, some behavior analysts are out of work; could they be repurposed to providing online support of families with children at home? Having eyes on the family is good, but it’s also introducing a risk that we will give advice that we don’t have an assessment to back up, or that is not fully safe to implement. And while I’d like to share ideas for behavior analysts to incorporate safety checks of your clients virtually, it’s most important for me to encourage you to reach out, right now, to your organization—and ask for your TEAM’S plan to do that. This is because different states and areas have different guidelines and requirements for you to follow depending on your local recommendations for HOW you monitor and report unsafe situations. You need to do it, but you should follow your local guidelines and state laws.

  1. Recommit to your role as a mandatory reporter for individuals with disabilities, the elderly, or children, if you are a therapist, teacher, etc.
  2. ACT as an employee: If you work for an organization, act by asking your company what their contingency plan is for all employees to fulfill this role given our emergency situation, and how you can help.
  3. ACT as an employer: If you own or lead an organization, stop right now and generate a brief plan for how you’ll support your team to fulfill their roles as mandatory reporters. Here are some ideas:
    • Write up a plan and email it out. Bonus points if you schedule an online meeting right away to disseminate it and give examples and encouragement.
    • Assign everyone a recommended frequency to make check-ins that specifically deal with the client’s physical well-being and mental health.
    • Give the team an example for what questions they can ask, and what they should avoid (if needed) to maintain everyone’s safety in the home they are looking at.
    • Tell employees to document the outcome of their checks (e.g., if they notice things that typically would indicate possible abuse or neglect; or if they notice something might be wrong that warrants another check-in from a supervisor on your team; if calls are made to CPS or APS)
    • Reinforce and encourage the behavior of employees who follow the plan, including having social support carved out for them so they don’t have to go it alone.

Telehealth provision is already a new skillset for some employees, including teachers, and if they are suddenly without any social support when they used to be able to walk down the hall to the counselor, administrator or psychologist on site, they may freeze and wait when action is important. It’s your job to make the unfamiliar but correct action as easy and supported as possible.

And here’s a notice: Social services haven’t closed down. In Colorado, not only are they still making visits, they are hiring. Hotlines are available and staffed with trained professionals to take your call.

Resources: Read guidance from the Behavior Analysis Certification Board on ethics, safety and more related to Covid-19.

Here’s more on how a few states are monitoring this issue.

Colorado:

Call 1-844-CO-4-KIDS if you suspect abuse or neglect

https://www.coloradocac.org/

For birth to 3 receiving services: http://coloradoofficeofearlychildhood.force.com/eicolorado/EI_QuickLinks?p=Home&s=EI-CO-Response-to-COVID-19&lang=en

Ohio: https://www.cleveland.com/court-justice/2020/03/staying-at-home-amid-the-global-coronavirus-pandemic-creates-new-dangers-for-victims-of-domestic-violence-and-abuse-experts-say.html

And in Texas, use this info:

https://www.allianceforchildren.org/

If you suspect a child is being abused or neglected, please contact the Texas Department of Family and Protective Services toll free at 1-800-252-5400, 24 hours a day, 7 days a week.

You may also file a report using the secure TDFPS website. Reports made through this website take up to 24 hours to process.

The Texas Abuse Hotline is 1-800-252-5400.

Connecting Behavior Analysis, Aging, Trauma, and Supervision

18 Monday Nov 2019

Posted by in adults, BACB CEU, Behavior Analysis, boundaries of competence, CEU, collaboration, Community, continuing education, Cusp Emergence University, dementia, ethics, mental health, supervision, teaching behavior analysis, TIBA, trauma, trauma-informed behavior analysis

≈ Leave a comment

Tags

, , , ,

Behavior Analysis, Aging, Trauma, and Supervision (or BATS, in honor of Dr. Janet Ellis).

This is the 18th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. It includes something new that we have been asked about: Companion notes for students and supervisees working through this information with the support of their supervisor.

I heard Jon Baker give a great talk on advances in behavioral treatment of gerontology the other day at COABA. It made me think of my students at the University of Colorado Denver and our supervisees. (There was also a fantastic talk on supervision and feedback by the incomparable Ellie Kazemi, whose book on supervision is out now). When they ask about clients other than autism who have benefited from applied behavior analysis, my supervisees are usually excited to read stories in which ABA changed the lives of people with dementia, brain injury, medical needs, and more. For example, an article from Baker (2006) Continue reading →

Seeing Snakes and Spiders

27 Friday Sep 2019

Posted by in BACB CEU, Behavior Analysis, boundaries of competence, CEU, children, collaboration, Community, continuing education, Cusp Emergence University, CuspEmergenceUniversity, edtiba, EDTIBA10, Education, Education and Trauma-Informed Behavior Analysis, ethics, mental health, resources, sale, teaching behavior analysis, teaching ethics, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

≈ Leave a comment

Tags

, , , , , , , ,

This is the 17th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

spider

What did you do when you saw this picture? Chances are you experienced some additional events beyond just “seeing it”. Did you jump? Experience an increase in your breathing rate? Use some choice verbal behavior? Avert your eyes? (And are you prepared to read on? Fair warning… there’s a snake coming up).

Seeing with fresh eyes

I noticed a couple of things about our culture, and fear responses, this past week.

My young daughter’s love for flap books—the kind where you pull back a piece of paper to reveal something—knows no bounds. So she was instantly drawn to a tattered old library copy (apparently she shares this love with lots of peers) of “Buzz Buzz, Baby”- with poorly rendered babies exploring “bugs”. Around the third page the baby pulls back a web flap to unveil, in the book’s words, “EEK! The itsy bitsy spider!”

Whenever I read the book to her I leave out the “Eek!”.

I think she can come up with that on her own, if she happens to, although chances are she’ll get it from me in a non-mindful moment. (In the 1980’s Cook and Mineka did a classic study in which infant monkeys “acquired” a persistent fear of snakes by watching their scared mothers encounter a snake).

Now that we’ve moved out to the country, we encounter our own “Itsy” (and many for whom that name is woefully inadequate) all the time. (I do recommend this thing called the BugZooka… it does work really well, if you like catch-and-release). Itsy and I go way back, and not necessarily in a good way, although I always appreciate her beauty. But I still want to be warned before you text me her picture, dad.

This summer, one tenacious spider (pictured, top) built a web, over and over, in a windy area outside the kitchen, where we see it numerous times daily. The first few (ok, few hundred) times I nearly jumped out of my skin. When I remembered in time, I was very careful to breathe and compose myself before walking to the sink with my daughter, where I’d point out the spider cheerfully and sing (with all the hand movements) the requisite song. Before long she was signing the song herself. Next I noticed myself no longer jumping when I saw the spider.

THEN… one windy morning Itsy was gone. Gone!

I didn’t breathe a sigh of relief.

I was surprised and curious to feel a strange emotion… like MISSING. I missed her! Was she alright? Would she come back? (She was. She did).

With painful awareness that this is temporary, I often marvel that my daughter’s eyes are not only young… they are unconditioned. They don’t have a lot of pairings with events like scary movies about this deep primate fear, being bitten, or seeing spiders while a parent jumps and screams. They are fresh, curious, hopeful eyes.

Yesterday we chanced upon something rather larger than even the biggest spider. It was this old girl… fat and long, with ring upon ring adorning her useful brown rattle. Depending on my readers, maybe you’ll be happy that instead of grabbing a hoe, I called a guy I read about in my new community’s online forum… apparently this guy LOVES snakes. “ANY snake’s worth my time”, he told me as he jumped in his truck. 35 minutes later he had driven up to our homestead, hooked it and taken it. Now it’s in a quite different rattlesnake heaven than the kind I had sort of planned to send it… blissing out in a protected wilderness area up near Fort Collins, I’m told.

rattler

As he removed our snake into a large vented box and curiously counted the rings (while remarking on how huge it was), the guy’s face was composed; he exuded a strange calm excitement. Normally, the fear response to snakes and spiders is part of our biology. Evolutionary biology has several theories why it’s present even in infancy, and why it might have behooved our ancestral mothers to experience more arousal and get out of there to protect their young in the presence of these critters. I can’t help but wonder what this guy’s history is like. Why does he love something that most of us are scared of?

Kids with traumatic histories

If you’re an educator going back to school, many of your kids are coming in with an avoidance response, or a “get out of there!” escape response, ready to go. Some of them will use these responses in the most annoying ways, dropping all their work on the floor or crawling under desks when you announce the quiz. But some of them have a special background you can’t see. For some, they will use these “fear responses” when they encounter “triggers” that you and I do not think of as scary.

Why is that?

Well, the things that were there when they experienced really bad situations are now “paired”, living together in their past, the same way I smelled an old lady yesterday wearing my own granny’s soap and got emotional thinking about my dear departed loved ones. Or the same way you hear a certain song from your high school dance and think about that year, or that person, or that kiss.

And that’s not all. Psychology explains in anxiety journals why, if you’re a person with an intense “fear” or phobia of spiders, not only do you spot them more quickly and tend to see them where your peers might see other things, like mushrooms or flowers faster in the SAME PICTURE—but to you, they also appear BIGGER.

What can we do about it?

How can we help students show up for their education and get all the learning opportunities they can… even when the school, teachers, and peers accidentally give them “fear related” stimuli all day long? (While psychology explains partly WHY these pairings happen, behavior analysis does too, especially if you read some relational frame theory, learn about respondent conditioning, and take a long-term functional analytic approach. Behavior analysis also goes a long way in helping the helpers undo some of the damage, teaching kids to approach adults and “unpair” adult attention from it’s previously bad parts: if I’m a student who has been through neglect abuse, my teacher coming over to me to praise my “good behavior” might not be a welcome stimulus at first… and my teacher’s praise, as well-intentioned as it may be, might not work).

Cusp Emergence University has been hard at work getting the new online training course ready for educators, and behavior analysts who work in education. We hope to help you to start answering these questions for yourself and your students and teams. On Monday, September 30, our course “Education and Trauma-Informed Behavior Analysis” opens to a 7 day sale (use the code EDTIBA10 for 10 percent off this CEU opportunity). We’re providing BCBA’s and BCBA-D’s with 3.5 continuing education credits, and 3 of those are in ethics.

coupon

Sign up now!

“Trauma-Informed Behavior Analysis” is redundant. Here’s why I use it anyway.

03 Monday Jun 2019

Posted by in adults, Behavior Analysis, boundaries of competence, children, collaboration, Community, contextual fear conditioning, Education, ethics, extinction, renewal effect, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

≈ 2 Comments

Tags

, , ,

“Trauma-informed behavior analysis”: Redundant term or useful phrase?

This is the 16th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Trauma-informed behavior analysis, abbreviated TIBA, is a phrase I’ve been using for a few years now to describe what I do to people outside behavior analysis. I do this because it helps them to understand how I apply the science, and not to suggest that “regular” behavior analysis should not address trauma. From those behavior analysts who have not been to my trainings, I often hear the question “Isn’t it redundant to describe behavior analysis as trauma-informed?” I would argue that the short answer to this question is “yes”. However, this article describes why the more important and longer answer is “yes—and it’s still useful”.

About this outline: As one of our current projects at Cusp Emergence, Dr. Camille Kolu is aggregating several years of data (including feedback from existing BCBAs, educators, foster parents, and social workers) in writing a set of articles on the topic of applying the science of behavior analysis to behavior change after a person has experienced significant trauma. This topic comes up frequently on behavior analytic forums. Please note that this brief outline does not describe the SAFE-T model (by which we advocate appropriate supervision, functional assessment, risk documentation, and environmental modification and training) or solutions to all the challenges it raises. Check out the other blogs on this topic, email us if you’d like to provide comments and questions, or see cuspemergenceuniversity.com for CEU and training opportunities.

Background: How is “trauma-informed behavior analysis” redundant?

I. The ethical practice of behavior analysis already requires it.

  1. We individualize (see BACB Compliance Code item 4.03)
  2. We should practice within our expertise (1.02)
    1. People whose lives are changed by major traumatic histories are changed in ways that distinguish them and their needs for specific supports, much like people who engage in serious self injury or have eating disorders are distinguished as a sub population who can benefit by specific expertise and training. We accept clients only if we are appropriately trained (2.01)
  3. We are already tasked with taking history into account, including analyzing functional relationships (3.01) and referring to consultation for medical needs as appropriate (3.02)
  4. We should refer and collaborate when needed (2.03a and 2.03b)

II. The application of behavior analysis already covers it (see Baer, Wolf and Risley 1968, 1987)

  1. Appropriate ABA tackles behavior of meaningful social significance, which it (behavior that is related to historical traumatic or aversive events) certainly is
  2. Appropriate ABA is conceptually systematic, and treatment of behavior after trauma may be conducted within the conceptual basis of behavior science
  3. We already have interventions that can be applicable and effective with this population (see our resources page for a partial reference list) including treatments for post traumatic stress disorder, using acceptance and commitment therapy principles from behavior analysis, and schedule related procedures including NCR for challenging behaviors; or see Fahmie, Iwata and Mead 2016; Iwata, Petscher, Rey and Bailey 2009; Richman, Barnard-Brak, Bosch and Abby, 2015)

III. The underlying science of behavior analysis and work on learning and behavior already describes phenomena related to behavior after trauma (see literature on reinstatement, contextual conditioning, respondent behavior, extinction in multiple contexts, etc)

  1. Laboratory work on extinction challenges from a respondent conditioning perspective can help us understand some of the unique challenges people face after experiencing trauma (see Bouton 2004)
  2. In basic research, “renewal” (return of behavior that was previously extinguished, after exposure to a conditioned stimulus- see Bouton and Bolles 1979; Harris 2000) is stronger with respondent behavior than operant behavior (Crombag and Shaham 2002)
  3. But younger behavior analysts may not have been trained to adequately appreciate respondent conditioning’s effects on behavior, and to teach others how to work with behaviors that are not operant. They may over-rely on using consequences to change behaviors, leading to criticism that “this stuff doesn’t work with my client impacted by trauma”. (Respondent conditioning is an item on both the 4th and 5th edition task lists, although respondent-operant interactions (see 4th edition, item FK-16) has been removed).

The current state: How is the phrase “trauma-informed behavior analysis” still useful (even needed) if it’s technically redundant?

I. I believe it’s helpful to both practitioners and client base.

  1. For practitioners: widespread practicing out of expertise incurs huge risks to clients, agencies, individuals and communities.
    1. Many people assume that the application of behavior analytic principles to trauma affected populations requires no nuances, and have harmed others
    2. There are not widely available risk assessments and tools to help those of us in this subarea document and collaborate as effectively as we need to
    3. There is not a collective understanding of how the collaboration can work, and many behavior analysts proceed unethically (although unintentionally)
  1. For clients: People needing the service are thwarted by bad (or just uninformed) press about ABA or and many think that ABA would be ineffective, harmful, or contradictory to their trauma-informed colleagues’ practice. This phrase gives me a way of introducing my services and assuring the recipients that I
    1. will, and do, consider their history of trauma as something that informs everything I will do for them
    2. will still be practicing behavior analysis, but from this specifically informed perspective
    3. honor both their specific background and their individual needs, using my own training and expertise in behavior analysis informed by additional experiences with social workers, those in the foster family community and others

II.  This phrase also gives me a way in, to talk to groups who haven’t had good experiences with behavior analysis

  1. including professional educators, school psychologists and therapists who have attempted collaborations that failed because clients’ trauma was overlooked or the practices were ineffective
  2. and including foster and adoptive families for whom the practice of “everyday ABA” included go-to strategies that were not (or at least not at first) helpful to their clients
  3. or people who haven’t had ANY experiences with behavior analysis (in my practice this includes people from these groups):
    1. Lawyers and courts
    2. Court appointed special advocates
    3. Social workers
    4. Trauma therapists
    5. Foster families and adoption agencies

Dreaming of the future

My goals include that one day in the near future,

  1. Treating behavior after trauma is a specialty in which behavior analysts can readily obtain experience from several field experts, similar to how they gather expertise specifically in treating behaviors such as severe self-harm, pica, or disordered eating, or behaviors in people with autism or genetic differences, or those in pediatric or geriatric populations.
  2. For recipients of behavior analysis, it will be simple and easy to find several options for treatment for behavior after trauma, from people with appropriate understanding, training and supervision, that can help them and collaborate effectively with other members of their team
  3. There are multiple funding streams to readily serve the population (examples: foster care, social workers, etc)
  4. And “everyday behavior analysis” is no longer viewed as contradictory to the support that would benefit people with historical experiences described as traumatic

Takeaway: I agree that saying behavior analysis should be “trauma-informed” can be redundant, since the basic science is rigorous enough to describe why our behavior is changed after and challenged by trauma. But I use it because it helps communicate what I do to people who have a specific history, and to help other behavior analysts understand how to establish an ethical approach to the intense documentation, risk mitigation, collaboration, and assessment that is required while using existing behavior analytic procedures to support those affected.

What’s your take? Send me a note or share a resource any time.

See or add to our growing reference list related to behavioral treatment of trauma.

CEU stands for Cusp Emergence University!

13 Tuesday Nov 2018

Posted by in About, BACB CEU, Behavior Analysis, boundaries of competence, CEU, continuing education, Education, ethics, learning, resources, risk analysis, risk assessment, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized

≈ Leave a comment

Tags

, , , , ,

Need training for your team in trauma-informed behavior analysis? Cusp Emergence University has launched! 

Come check out the site, sign up for one of Dr. Kolu’s courses, or just have a look around.

While we’re beta testing, save 15% on 3 CEU’s in a 2.5 hour continuing education course (Introduction to the Ethics of Trauma-Informed Behavior Analysis).

This course is for intermediate audiences interested in learning more about the ethics of trauma-informed behavior analysis, or using behavior analysis to provide responsible, evidence-based and sensitive support to individuals whose backgrounds include early or serious adverse experiences. Take this course to prepare your practice and team and plan for the increased risks associated with this population. BACB certificants receive your certificate upon completion of the course, which includes quiz questions to help keep you engaged. Course includes 2 ethics CEU’s.

DISCLAIMER: Dr. Camille Kolu of Cusp Emergence is a Behavior Analysis Certification Board (BACB) approved ACE provider. Advertisements for new continuing education opportunities (per the board requirements) will often be placed here. Check cuspemergenceuniversity.com for the full details, to enroll in courses, or to learn more about the continuing education opportunities provided.  The BACB does not endorse any individual courses.

Come back to the tab Cusp Emergence University, or check out CuspEmergenceUniversity.com  any time for updates on courses in development.

Spotlight on team role: CASA (Court Appointed Special Advocates)

07 Friday Sep 2018

Posted by in Behavior Analysis, CASA, children, collaboration, Community, Court Appointed Special Advocate, Education, ethics, resources, Uncategorized

≈ Leave a comment

Tags

, , ,

This post is part of the series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, Ph.D., BCBA-D.

Why is this in the trauma-informed series? Behavior analysts have ethical responsibilities to disseminate information about our field (Compliance Code item 6.02), cooperate with others (2.03), individualize treatment based on the contextual variables involved in our clients’ cases (4.03), and identify, eliminate and communicate about the environmental constraints on the effectiveness of our treatment plans (4.07). All four of these ethical imperatives can be positively impacted by involving CASA! And these ethical areas are even more important when treating behavior of a person who has been through trauma, abuse or neglect.

Spotlight on team role: CASA, or Court Appointed Special Advocates

Cusp Emergence has had a busy summer! We’ve been continuing public speaking and training, spreading the word about trauma-informed behavior analysis to community partners. There are few things more rewarding than working on a case with a partner who asks us to come back and train their agency, providing continuing education for their team members. This is even more exciting when the provider is newer to behavior analysis. We love disseminating information about the field and hearing from the community!

This post is a shout-out spotlighting CASA. Never heard of them? These people form a compassionate army of people from all walks of life providing long-term relationships and supportive advocacy to local children whose lives involve the family court and foster care system. Some organizational positions are paid to keep the group running, but many are volunteers. The program is nationwide, and depending on the location and jurisdiction, a CASA may be a guardian ad litem or volunteer their time. Some are young professionals, others are retirees; they have in common a passion for children who have experienced inconsistency in caregiving, often including abuse and neglect. Court Appointed Special Advocates receive extensive training and may donate their time to attend visits with the child in the child’s group home, foster home, adoptive family home, residential facility, or hospital. I see them advocating at meetings, attending court dates to speak in the child’s best interest after gathering information; visiting at school; and attending trainings where I provide reviews of behavior assessments and plans. For some children removed due to abuse and neglect, a CASA may be the ONE familiar face present at family court, several foster homes, many schools, and holiday parties held in the hospital where the child was placed after using aggression and receiving a medication change. Caseworkers are familiar too, but may change more than the court appointed special advocates—many of whom follow a child for life.

Maybe you’re a BCBA reading this, thinking “How does this relate to my role?”

First, if you’ve got a client in foster care, you can ask the client’s caseworker if the person has a CASA. If so, you can offer to meet with them and learn more about their role and their history with the person. (I have never had a CASA refuse to meet with me, although this is on their own time—more commonly they are excited to learn about behavior supports, and often advocating to get me on their other cases after they learn more about behavior analysis).

I also train all my client’s CASAs in the functional behavior assessment results and behavior plan. Why?

  • On their visits they may see challenging behavior and want to know the best, and most supportive, way to respond or prevent challenges.
  • They may conduct unannounced visits in the child’s home or school, and these may be followed by increases in challenging behavior that the team finds confusing. It is helpful to educate the entire team, CASA included, on the changes in behavior that may occur after the child is visited by an unannounced person associated with previous family visits, even if the child typically enjoys visits with the CASA.
  • Since the CASA is by definition an advocate, they can be very helpful in sharing information with the court or team that help them to put behavior services in place. In some areas, services can be more difficult to fund if a child has severe behavior needs but not a diagnosis like autism that makes it easy to get insurance on board. In these cases, the county or court may step in and require or help fund some behavioral treatment that is instrumental in helping the foster family understand and manage the child’s behaviors.

Thank you so much, to Becca and Mara at CASA of Adams and Broomfield Counties! It was fantastic to see so many of your team last month.

Want to learn more?

Check out the national CASA movement:

http://www.casaforchildren.org/site/c.mtJSJ7MPIsE/b.5301295/k.BE9A/Home.htm

Are you local to the Cusp Emergence community around Adams County, Colorado? Check out the Adams County CASA page (and be sure to attend their free informational event on October 18!)

https://casa17th.org/

Read about CASA in the news, with stories about topics like how to become a CASA…

https://www.caller.com/videos/news/2018/07/12/how-become-court-appointed-special-advocate/35522163/

or read from the perspective of a judge whose decisions are informed by their work:

http://www.sj-r.com/x1374045505/Court-Appointed-Special-Advocate-program-history

Find the Behavior Analysis Certification Board Compliance Code here:

https://www.bacb.com/wp-content/uploads/2017/09/170706-compliance-code-english.pdf

 

 

 

 

 

Too risky to document risks?

17 Tuesday Jul 2018

Posted by in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, boundaries of competence, collaboration, Community, Education, ethics, resources, risk analysis, risk assessment, risk versus benefit analysis, supervision, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized

≈ Leave a comment

Tags

, , , , , ,

This post is part of a series on trauma-informed behavior analysis by Dr. Camille Kolu, Ph.D., BCBA-D.

When treating behavior concerns after trauma, we may find that clients exhibit risks to themselves, risks to their community, and risks to caregivers that should be documented. Why have behavior analysts sometimes turned a blind eye to documenting these risks? Read on to discover some common reasons I found in the field, and ways we can address them. 

When it’s too risky to even consider the risks

Our field has adopted a Compliance Code which mentions the need to document risks. As an instructor for courses in a BACB-approved course behavior analysis course sequence, I use a textbook that provides sample templates for documenting and analyzing risks. And as a practitioner, I have found that my analysis or assessment of risk is almost always helpful to a case (as in some situations I’ll describe below), not to mention that it’s quick and simple it is to do.

Despite these facts, most behavior analysts I encounter do not analyze risks in any sort of written format. The behavior analysts around me range from BCBA-Ds to RBTs, and many have expertise and long careers. Why are we averse to documenting risks?

I have been researching the answer to this question for several years, and often the answer is “because I don’t have a good risk assessment”. So I made some and piloted them with different agencies, working through the problems of how to identify, define, document and mitigate the risks related to the populations with whom I work most closely. But at a recent training opportunity I received a different kind of answer, and I think it’s too important to keep to myself.

Some of the BCBA’s I talked to at that event were not documenting risks, they acknowledged, because it was just too risky.

At first it seemed counterintuitive. If I was providing a new document that made it easy to document several options, and the potential risks and benefits of each, wasn’t that inherently reducing the risk? No, it turns out. To many of us, highlighting a risk necessarily imposes some degree of liability.

We’ve faced this challenge before. In pointing out a problem we may become partially responsible for solving it, as some educators have learned the hard way when their schools are upset with them for discussing the observations of a student’s difficulties outside of the official process. This responsibility may carry a financial burden or create an unsolvable problem in a resource-poor area. And some pediatricians I know have mentioned the frustrating dilemma of being given a new depression screen for teens or moms, only to have nowhere to go with the results.

A new ethical responsibility is only as useful as your agency’s process to fulfill that responsibility, and procedures to support the people implementing the new responsibilities.

And in the discussion with the BCBA’s that day about risk documentation, I learned something really interesting. The specific language I used made a huge difference in their willingness of adopting a new procedure.

When I called it a “risk assessment”, BCBA’s were unwilling to adopt my new “assessment”, even if it was backed up by the compliance code and plenty of evidence and anecdotes how it has supported my work.

But when I called it a “risk versus benefit analysis”, they were willing to try.

The difference?

“Risk assessment” is a loaded term that carries legal weight in many contexts.

On the contrary, the other term (“risk versus benefit analysis”) is something that I use daily, and that is simply a process of documenting and analyzing the several different options available, together with their respective potential risks and benefits. It’s called for by the Compliance Code (and discussed by Bailey and Burch in their Ethics text).

According to the Compliance Code, “a risk-benefit analysis is a deliberate evaluation of the potential risks (e.g., limitations, side effects, costs) and benefits (e.g., treatment outcomes, efficiency, savings) associated with a given intervention. A risk-benefit analysis should conclude with a course of action associated with greater benefits than risks.”

The Compliance Code mentions risks in several places. In 2.04b, we are to consider risks of performing conflicting roles (e.g., when we are clarifying third party involvement in services). In 2.09c we are asked to use a risk-benefit analysis as part of our process in deciding between different treatments. And in 4.05, we are asked to work with stakeholders to present the potential risks versus benefits of which procedures we plan to use to implement program objectives. 7.02 asks us to consider risks involved, when there may have been an ethical or legal violation by a peer. And of course, we consider the potential risks and benefits when doing research (9.02).

The Task List does not mention “risk” by name, but alludes to the process when requiring that we are required to be able to state and plan for the possible unwanted effects of reinforcement (C-01), punishment (C-02), or extinction (C-03), as well as behavioral contrast (E-07). Similarly, the Code makes it clear that we are to identify potential for harm with using reinforcement (4.10) and identify obstacles to implementing recommended treatment (4.07).

In my practice, the most efficient way to meet all these objectives and more, is to complete a risk-benefit analysis. I love to include sections on mitigating the risks I do identify, so that the team can make an informed decision about what resources, training, information or support they will need to implement the least risky option.

And a final benefit I’ve heard many stakeholders mention during this process (and typically I do the analysis as an open discussion in which they are involved and brainstorming), is usually stated like this: “I didn’t think we had any other options, but when we approached this with a goal to identify alternatives and the risks and benefits of each, we uncovered several more”.

The risk versus benefit analysis is something I document, add to a treatment plan or employee or client file or IEP, or simply something I share with the team in writing and in person to solidify systems support for my next move. Recently, the following situations were ameliorated by using a transparent risk versus benefit analysis. Outcomes included increasing appropriate funding; securing appropriate medications; identifying appropriate caregivers; funding appropriate training; and improving client satisfaction.

-what kind of residential facility would be most appropriate to move a client to

-whether to discharge a client now or later

-whether to use a cheaper program with fewer resources or a costly one with many

-whether to put a client in a foster home in a potentially risky but supportive situation

-whether to delay an assessment to have an operation

-under what conditions should we discontinue a client who violates our informal no-show policy

-what caregiver to select from several available

-how to appropriately include police contact in a plan in a way that reduced long term risks

-what medication to decrease and when

-whether to put a student in a restrictive school with more behavior support, or a less restrictive placement with more social interaction options

As you can see by the last two, sometimes these decisions are not cut and dry. They depend on the team and family input, and one family may weigh a given outcome more heavily than another.  Everyone has a history. To do these analyses in a compassionate and open way is important, and sometimes we don’t agree. To involve high level stakeholders and funders is critical as well.

What are the risks of doing a risk-benefit analysis? Perhaps you’ll highlight more risks than you thought were there; perhaps you’ll have to take some responsibility for the outcome of your recommendations. But what are the risks of avoiding this important process? If you are certified, your responsibility as a behavior analyst “is to all parties affected by behavior-analytic services” (e.g., 2.02). So are there risks of not documenting risks? Sure. You could cause harm or be negligent if there is a known risk you didn’t plan for or discuss with the team. Just like there are risks, there are benefits too. Doing a good risk versus benefit analysis is certainly a helpful cusp for supervisors and behavior analysis leaders to acquire! Many times we have uncovered risks that can be totally avoided next time if we were to act now to change or solidify policies, or use preventative measures in the future. A risk-benefit analysis can be a wonderful contribution to discussing lessons learned.

There are more options to be uncovered. Go out there and find and document them!

Want a resource? Check out the 3rd edition of the Bailey and Burch text Ethics for Behavior Analysts (2016), read more on Cusp Emergence , or check out a risk versus benefit tool (I like to do this on a whiteboard with my teams).

Convinced? Have a question? Drop us an email. And thanks for reading about this important topic. We’d love to see how YOU document and discuss risks!