Building The Best Therapy Team
Updated: Jun 16, 2019
Originally posted at http://www.bsci21.org/building-the-best-therapy-team/ on March 28th, 2017
About a year ago, I was attending an ABA conference and I overheard the conversation of two BCBAs in front of me while we were packed together waiting to enter a presentation. They were both complaining of their oversized workload when one of the therapists asked the other why she didn’t give some of the work to her RBTs (Registered Behavior Technicians). The BCBA’s response, minus some cuss words, was that her RBTs were too lazy to do any of that work, they would do it wrong, and they didn’t care about their jobs. While her rant was slightly amusing after a long day at a conference, my first thought was how sad that was for her and for the therapists that worked under her.
In my experience, people don’t want to do badly, but they do get frustrated and mentally give up when they’re not supported, not trained properly, and not recognized for their effort. The reality is that the turnover rate for behavior technicians is exceptionally high, 38% according to a 2009 DSP Wage Study for all direct support care positions and more recent studies showing 45-75% for behavior technician positions working with adults (Kazemi, Shapiro, & Kavner, 2015). As BCBAs, trained to analyze and shape behaviors, we should be working to change that.
We use the principles of ABA with our clients on a daily basis, but what about with our staff? Behavior technicians are the foundation of providing effective therapy; they are out there every day building rapport with the clients, running your programs, and handling the brunt of the challenging behavior. Our programs succeed or fail based on their skill, understanding, and inclination. Here are a few tips to make sure you shape the best foundation to your therapy team.
1) Get Feedback
When I started in a new clinic, my first mission was to find out about my clients by asking my team. I wanted to know what the client’s behaviors were like and what new programs or program updates they needed since nothing had been updated for a couple of months. The response from almost every person was “You’re the BCBA, we can do whatever you want.” It wasn’t a statement of apathy, but clearly something they had been told from their previous supervisor.
BCBAs are integral to an ABA program; we’ve spent years getting degrees in this field, we write the behavior plans and programs, we assess clients, and we analyze and make decisions based on data. But no matter how amazing your programs are, if the direct therapy staff don’t trust your judgement, it will never be implemented correctly. Encourage your staff to be involved in treatment planning instead of just telling them what to do. Explain why you’re working on skills or behaviors in a certain way and what the future direction of the program is. Let them ask questions about it and give their input, they are the ones that are with the clients every day. You might not use all of their suggestions, but if they’re thinking about a different way to implement something and you don’t discuss it with them, they might end up trying it on their own while you’re not there.
Feedback isn’t limited to client programs – also get feedback on your supervision. Find out how they like to receive feedback in session, if you are training them on things that are relevant to them, and if there’s anything else you can do to support them.
2) Be Reinforcing
If you get a new client or an existing client gets a new therapist, one of the first things we do is pair ourselves with reinforcement. We are always working on building and maintaining rapport with clients, and we need to make sure we do this with our staff as well. If you are new to a company or have a new staff member, before you start placing demands, you need to establish a relationship.
Use regular non-contingent reinforcement by bringing donuts or coffee in the morning, take everyone out for lunch, or plan monthly get-togethers like happy hour (don’t let it get too crazy and maybe just buy the food, not the drinks), bowling, or movie night. Remember the ratio of 8:1 positive comments to criticisms to make sure you’re not overwhelming them with things they’re doing wrong. And be present! If the only time the therapists see you is when you’re coming to fill out a supervision form and judge the work they’re doing, you will quickly be seen as an SD for punishment.
3) Provide Feedback
People that get into this profession want to do a good job. It’s unlikely that they decided to work in such a demanding field with not great pay to intentionally be unsuccessful. Providing consistent and meaningful feedback will help your staff become great therapists and have a direct impact on your client’s success (Reid & Parsons, 1995). We need to be giving them constant feedback to shape their behavior and help them become great therapists. You can use a supervision form like described here, or create your own, to evaluate their teaching procedures, behavior management, and data collection accuracy.
Always be fair and neutral, and have a training plan put in place across all therapists if they ever begin to struggle in a certain area. If there are things they need to change, give them clear and descriptive instructions. Instead of saying “Well, we need to work on the way you say some things”, tell them “When the client starting throwing toys, you kept telling them ‘no’ and ‘stop’. Do not say that, instead give them an instruction of an incompatible behavior.” Feedback and praise should be given as immediately as possible and their results should be documented so you can see their progress and share it with them. And don’t forget to reinforce their behavior for improving and maintaining their skills.
Still Having Problems?
What if you’re doing all of these things and you still have a therapist that isn’t following protocol, engaging in off-task behavior in sessions, or isn’t taking feedback appropriately. This would be the time to set up a private meeting outside of therapy to discuss the issues. The elements of due process laid out by HR consultant Paul Falcone (Falcone, 2010) state that it is important to clearly and neutrally define the problem, discuss the solution, tell them the consequence of not changing their behavior, and give them a timeline of when the issue needs to be resolved. So your conversation might go something like this:
“You’ve been arriving 30 minutes late to your visits. You need to arrive 5 minutes before your scheduled visits. If this does not improve, you will be written up and after 3 write ups you will be let go. We will meet again in two weeks and I need to see improvement within that time.”
Also, find out why they are having these problems and offer support to help them remediate their behaviors. Do they need more training? Are they having personal issues that are interfering with their work? And look at your own behavior, is there anything you are doing that is reinforcing their problem behavior? Discussing these topics with staff is never comfortable for either party, but the purpose is to tell them what they need to do to keep their job, and people usually want to keep their jobs. Not everyone is going to be a perfect fit for this field, but by incorporating ABA into our staff interactions, we can work to reduce the high turnover rate facing our behavior technicians and build a happy and effective team.
Anderson-Hoyt, J., McGee-Trenhaile, M., Gortmaker, V. (2009). 2009 Direct Support Professionals Wage Study. American Network of Community Options and Resources. http://www.ancor.org/sites/default/files/pdf/ancor_wage_data_summary_2009.pdf
Druskis, Melissa. (2016, July 17). Product Review: ABA Supervision Form. Retrieved from https://youtu.be/LRXUtbu8Yeg.
Falcone, Paul. (2010). 101 Sample Write-Ups for Documenting Employee Performance Problems. New York: AMACON
Kazemi, E., Shapiro, M., Kavner, A. (2015). Predictors of intention to turnover in behavior technicians working with individuals with autism spectrum disorder. Research in Autism Spectrum Disorders, 17, 106-115. http://www.sciencedirect.com/science/article/pii/S175094671500077X
Reid, D.H., Parsons, M.B. (1995). Training residential supervisors to provide feedback for maintaining staff teaching skills with people who have severe disabilities. Journal of Applied Behavior Analysis, 28(3), 317-332 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279829/pdf/jaba00005-0077.pdf