Tag Archives: risk assessment

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

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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!

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

05 Saturday Aug 2017

Posted by in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, Community, Education, ethics, risk assessment, supervision, teaching behavior analysis, teaching ethics, trauma, Uncategorized

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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.