By Clelia Sigaud, M.S.
bSci21 Contributing Writer
Even as a not-yet-certified student of behavior analysis, it is incredibly easy for me to personally connect with virtually all guidelines within the Behavior Analysis Certification Board’s Professional and Ethical Compliance Code for Behavior Analysts. After a few years as an Educational Technician, Behavioral Health Professional, and now Special Education Teacher, working within K-12 programs displaying various levels of adherence to an Applied Behavior Analysis treatment model, I can clearly see the applicability of the guidelines, and why they are needed.
I live in Maine. If you’re not sure whether we even have hot water up here, you’re not alone. Rural areas such as Maine don’t usually spring to mind when picturing hotbeds of innovation. Although my state is quite up to speed in terms of plumbing, we are facing what many other areas also experience – a significant shortage of behavior analytic services. Contemplating clinical practice in an environment such as this involves recognition of some potential major pitfalls in the ethical practice of behavior analysis within an organization or setting that is not incentivized to be aware of, familiar with, or supportive of, compliance with the BACB’s ethics code, particularly those pitfalls that might be amplified by practice within a geographically rural and underserved area such as Maine. Such a situation provides for some unique and often daunting challenges that are simply not present in a private ABA-focused program, or in a more diverse urban environment.
Something I was very surprised and dismayed to learn as I explored research on the topic of ethical behavior among Board Certified Behavior Analysts (BCBAs) was that some clinicians working in autism services incorporate into their practice “treatments” that are not validated by evidence (such as sensory integration and floor time) and even some that can be harmful (such as facilitated communication). Amazingly, research even suggests that not all BCBAs use ABA within their practice (Schrek & Mazur, 2008)! It goes almost without saying that using non-scientifically-validated interventions is itself a violation of the ethics code (standard 1.01). Thus, simply modeling the behavior of other BCBAs in the field is not a guaranteed way to gain the majority of one’s ethics training.
Ethical behavior within the field of behavior analysis is governed by the BACB ethics code, and can therefore be rightly termed “rule-governed” behavior, which can become insensitive to immediate consequences. An obstacle to ethical practice, in my experience and observation, is that very often the analyst’s behavior comes under the control of context-specific contingencies rather than under the control of overarching rules. This is a matter that, in my opinion, must be addressed as we work towards full compliance.
Although the unique challenges posed by the practice of behavior analysis within rural and/or underserved areas have not been abundantly researched as of the present, such concerns are well established within the broader field of psychology practice. Research indicates that vigilance with regards to ethical compliance, particularly as regards dual relationships, scope of practice, and client referrals, is especially important in rural areas. Research also notes that psychological services providers in rural areas are often generalists “by default” due to the diverse nature of their caseloads (Helbok 2003). While that makes sense, we cannot use such behavior patterns or findings from similar professions to become lax in our own adherence to our professional code.
Although unavoidable, the “shades of gray” that might appear in the BACB guidelines themselves can leave practitioners in a dilemma, particularly when they seem to potentially contradict each other. Caseload sizes serve as a good example. Although no definite guidelines regarding caseload sizes exist, the level of involvement required of the BCBA (particularly clear in standards 2.0, 3.0, 4.0, and 5.0) implies limited numbers of client caseloads, and have subsequently caused quite a stir in some behavior analytic communities. Many professionals I know become concerned when the standards seem to conflict with the realities of the field. A germane and all-too-realistic scenario would involve a behavior analyst who is compelled to give up his position due to unethical demands from his employer regarding caseload size, thereby in-effect revoking services for all clients without taking steps to transfer to another clinician. While the guidelines seem clear on the mandate to take swift steps to remediate a position in which ethical practice becomes impossible, doing so by means of voluntary termination of employment would realistically tend to occasion other ethical concerns arising from the discontinuation of services (standard 2.15), especially in poorly-served geographic areas, where another provider may be unavailable. What a difficult situation!
The good news, in terms of building high quality working relationships to help solve these clinical problems, is that school administrators making special education program decisions appear to, as a group, be motivated by rule-adherence and a focus on best interests of students (Frick et al, 2013). The difficulty lies partly in that administrators and behavior analysts conceptualize ethical rules and student best interest in somewhat different ways, depending on specific situations.
Another common situation in my area involves encountering a client whose interfering behavior represents a challenge outside of one’s scope of practice, without having the necessary resources to seek adequate supervision. The guidelines are clear on this – the clinician must seek supervision or, if not available, refer to another practitioner (standard 20.1). However, that may seem impossible in some situations. For example, a lone BCBA in a public school system in Maine may have no one to turn to for clinical advice on a difficult case besides possibly an outside consultant, who would have to be paid for by the district. Given such a situation, the guidelines indicate that the client should be referred to a clinician competent to treat the presenting behavior problem; however, again, we hit against the underlying difficulties associated with the underserved nature of many rural areas. What if there is no clinician to refer to, either because such a person truly does not exist or because potentially appropriate professionals are inaccessible due to financial or scheduling reasons? Add to this an insistence from school administrators and teachers that the client remain on the BCBA’s caseload, and we have a case of behavior that should be rule-governed becoming prone to influence based on local consequences.
Although referring to a former version of the ethics guidelines, Hemingway (2003) is quite cogent when he comments that “abiding by these guidelines is difficult; competing contingencies such as those involved in economic survival and more proximal stimulus controls might obfuscate critical variables. The behavior analyst might ignore or misjudge his or her limits. The behavior analyst is advised to remember that certification establishes minimum competency in regard to essential content, but does not establish general competency in all settings/applications” (p. 152).
Perhaps the most common and troubling component of attempting to ethically practice behavior analysis in underserved areas, particularly within a non-behavior-analytic organization, has to do with the ethical responsibilities BCBAs have to their supervisees (standard 5.0). In my anecdotal observation, it is extremely frequent for clients to be placed under the direct supervision and care of front-line staff who are lacking pivotal skills that would enable them to understand and deliver behavior analytic programming. The main concern here is to ensure that individuals are not tasked with implementing treatment if there is a chance that they will do so incorrectly. Behavior change programming is effective – and ethically utilized – only to the extent that it is understood and carried out correctly by the other change agents on the client’s treatment team. It is a serious violation of a BCBA’s ethical duties to delegate program implementation to persons who are not able to perform the job. Nevertheless, devoting appropriate amounts of resources to delivering staff training can be physically impossible for a BCBA whose caseload is too large. Often, resources are so strained that allowing for basic safety needs of clients takes precedence over providing high quality training to staff members. The use of substitute staff in school systems to cover short- or long-term staff absences or shortages creates a host of additional issues, as often these staff members have no relevant experience and are not eligible to receive any of the ABA-based orientation materials that new employees would be receiving prior to working with clients.
I would argue that the “shades of gray” which we all experience in this field to an extent, falls especially heavily on paraprofessionals. Lacking advanced training and subsequent clinical judgment, they are left in critical need of high quality supervision. Interestingly, research indicates that employees and supervisees tend to respond to prompts of a contextual nature (such as that offered by the work group), as well as those of a strictly managerial nature (Kalshoven et al, 2013), meaning that behavior analysts would do well to consider the overall environment in which their supervisees are functioning within the workplace. I’ve written more specifically about direct care staff here.
I do wonder about the extent to which BCBAs working within public schools or other non-behavior analytic settings can ever have full control over the competency of the individuals hired to implement direct programming and facilitate behavior change. I often hear variations of the following question: “Is it realistic to expect that a BCBA will have a caseload so small as to be able provide the theoretical and hands-on training necessary for all direct-care staff to correctly implement programming?” It would seem that the answer to that question lies partly in the control of professionals who function in a different capacity within the school community; namely, administrators. Most importantly, though, the real response lies partly in recognizing that whether something feels “realistic” or not in a particular practitioners’ perception does nothing to alter the fact that the ethics code must be followed.
As the BACB itself has made abundantly clear through the revamped grievance process, we need to use antecedent interventions and shaping to arrive at solutions to these significant ethical and clinical challenges. It appears that building high quality collaborative relationships with relevant stakeholders, such as district administrators, is of paramount importance prior to any potential conflict arising. Nevertheless, at the end of the day, we need to know what our obligations are in order to comply with ethical guidelines irrespective of what other professionals may pressure us to do. Regardless of personal contingencies, we need to be willing to give up our jobs, if necessary, rather than compromise our integrity. As daunting as the road ahead sometimes seems, ultimately I am excited to become a BCBA and join the ranks of a profession with such extremely high standards for its members.
Behavior Analysis Certification Board (2016). Professional and Ethical Compliance Code for Behavior Analysts. Littleton, CO.
Frick, W. C., Faircloth, S. C., & Little, K. S. (2013). Responding to the Collective and Individual “Best Interests of Students”: Revisiting the Tension Between Administrative Practice and Ethical Imperatives in Special Education Leadership. Educational Administration Quarterly, 49(2), 207-242. doi:10.1177/0013161X12463230
Helbok, C. M. (2003). The Practice of Psychology in Rural Communities: Potential Ethical Dilemmas. Ethics & Behavior, 13(4), 367-384.
Hemingway, M. (2003). Do No Harm — An Ethical Dilemma and One Possible Way Out. Behavior Analyst Today, 4(2), 151-153.
Kalshoven, K., Den Hartog, D. N., & De Hoogh, A. H. (2013). Ethical Leadership and Follower Helping and Courtesy: Moral Awareness and Empathic Concern as Moderators. Applied Psychology: An International Review, 62(2), 211-235. doi:10.1111/j.1464-0597.2011.00483.x
Schreck, K. A., & Mazur, A. (2008). Behavior analyst use of and beliefs in treatments for people with autism. Behavioral Interventions, 23(3), 201-212. doi:10.1002/bin.264
Clelia Sigaud, M.S. is a teacher to children with developmental disabilities in urban Maine (to the extent that “urban” and “Maine” can be used in the same sentence). She has several years of experience working with special needs individuals, from preschool through age 20, in a variety of settings. Outside of work, she is earning her doctorate in School Psychology from the University of Southern Maine. Her interests include functional communication training, interventions for sexualized aggression/sexually problematic behavior, treatment of self injury, paraprofessional training, and ethical practice within the field of ABA. In her spare time, she enjoys authoring her own social stories. You can contact her at [email protected].
Hi Clelia, Thank you for providing your experiences with ethical dilemnas in such a thoughtful and concise manner. I too have provided services in rural areas and within school districts where “policies and procedures” seem to overlay clinical practices. I have found that providing the code of ethic as supporting practices to HIPAA an FERPA, administrators and managers become cooperative and compliant. To the issue of caseload sizes, the BACB has published a set of guidelines for insurance providers, which I have used as an example for schools to follow as well. Here is the link for your quick access: ABA Practice Guidelines for Healthcare Funders and Managers – http://bacb.com/wp-content/uploads/2015/07/ABA_Guidelines_for_ASD.pdf
If you think it is difficult adhering to the ethical guidelines in rural areas of the USA, try following them when if you’re in Kuwait, rural Scotland or France. All of the issues you’ve raised are even more problematic in those settings. At times it seems that BACB guidelines are written mostly with insurance-funded American models of delivering ABA interventions in mind.
It’s not always clear exactly they are supposed to apply in situations where the behaviour analyst has a consulting/non-directive role as part of a multi-disciplinary team where the leader is not a behaviour analyst. Some countries forbid the use of non-eclectic models for people within their education systems. Is it even possible to adhere to the ASD guidelines in those circumstances? Some people may be the only BCBA within a 100 mile radius yet they are supposed to refuse to provide treatment to the children of those they have a dual relationship with.
“Regardless of personal contingencies, we need to be willing to give up our jobs, if necessary, rather than compromise our integrity.”
I’ve had to do this in the past but having said that I’ve known other behaviour analysts who have joined organisations and have had to compromise the integrity of the treatment they provided due to organisational constraints but who have – over time – changed the structure of the organisation so that quality interventions that fully adhere to ethical guidelines are used.
There’s also the question of who your client is in some situations. For example, a behaviour analyst who was hired as a teacher for a large school might be obliged by their contract to implement sensory integration interventions due to a recommendation by an OT. It might be that in this situation the behaviour analyst might be obliged to terminate their employment. However, a behaviour analyst hired by the same organisation to provide several FAs and BSPs to the same organisation or to train their staff in implementing DTT and NET could do so without breaching any guidlelines. In the former situation, the student probably gets better treatment because they have greater access to the BCBA. In both situations, the student still receives the SIT. Who actually benefits in these kinds of scenarios?
Don’t get me wrong, I’m not saying that the guidelines are necessarily wrong in these kinds of situations, it’s rather that they seem to have been penned without these kind of situations in mind. I’ve probably simplified a lot in the above examples. It would be better if they provided a little more relevant guidance that are relevant to the nuanced situations we find ourselves in where it’s not a simple case of a BCBA supervising BCaBAs and RBTs working in the homes of kids with autism in the care of their parents.
Amen!! Thank you for knowing our ethical code! Many BCBAs think ignorance will be acceptable as a pass for violating the codes, but it’s not.
This article is so on point! Have you become certified as a BCBA yet? If so, what would be your follow-up to this article?