Ethics Code: Responsibility to Clients and Stakeholders (Section 3)

Section 3: Responsibility to Clients and Stakeholders

This week's focus is on Section $3$ of the ethics code for behavior analysts, which addresses our responsibilities to clients and stakeholders. This section emphasizes procedural and process-oriented practices for safeguarding client rights, distinct from intervention design which was covered last week. It is crucial to have a copy of the ethics standards readily available for reference.

Upholding Client Rights and Best Interests

• Foundational Principle: Bernd and Sadavoy describe following the law as the "lowest rung on the ladder" for ethical conduct. Behavior analysts are responsible for upholding distinct client rights beyond legal compliance.
• Key Client Rights: These include the right to safety, the right to consent, and the right to redress grievances.
• Core Ethical Directives: Acts in the best interest of clients, support client rights, maximize their benefits, and do no harm.
• The Right to Safety: This extends beyond physical safety to include the client's feeling of safety. Clients have the right to access a clinician's credentials and critical background features.
  • Connection to Sunland Training Center: The example of Sunland Training Center highlights the importance of this, where the principal clinician, despite calling himself a behaviorist, lacked actual training in behavior analysis.
  • Practical Application - Agency Transparency: Behavior analytic agencies should provide easily accessible information about their chief officers, executives, or clinicians (e.g., via an "About Us" or "Our Team" link on their website), including degree origins and board certification dates. Lack of such disclosure raises ethical questions about transparency and accountability.
• Identifying and Prioritizing the Client: As discussed by Jacob Sadavoy, it is essential to clearly identify and prioritize the client, separating their rights and interests from those of the funding agency.
• Scope of Competence and Capacity: Behavior analysts must not accept clients whose needs exceed their time, capacity, or fall outside their scope of competence. Open and transparent communication with the client about these limitations is crucial.

Responsibilities to Stakeholders and Service Agreements

• Identifying Stakeholders: It is important to identify all relevant stakeholders and clearly communicate our obligations to them at the outset of services.
• Service Agreement: A formal service agreement must be:
  • Signed Prior to Services: Ensures clarity for all parties before service commencement.
  • Written and Reviewed: Clearly outlines expectations for both the behavior analyst and the client.
  • Dual Purpose: Protects both the behavior analyst and the client.
  • Examples of Stipulations: May include caregiver presence for home sessions (protects BA) or scheduled family meetings (protects family).
• Funding Agreement: A separate document or section within the service agreement should detail compensation, billing practices, and payment distribution.
  • Fair and Accessible Rates: When providing independent consultation, behavior analysts must stipulate a fair and accessible rate, avoiding "favors" in a professional setting.
  • Clarity and Protection: Written agreements on costs and included services protect both the behavior analyst and the client, fostering transparency and preventing disputes.

Collaborating with Others (Third-Party Services)

• Client's Best Interest: Consulting with other providers is generally in the best interest of clients.
• Professional Expertise and Perspective: Behavior analysts should consider what they can learn from others while also contributing their unique behavioral perspective.
• Behavior Analyst as a Third Party: In legal terms, the client is the "first party," the funder or arranger (e.g., school district, state agency) is the "second party," and the behavior analyst is the "third party."
• Conflicts of Interest: When collaborating or providing services arranged by a second party, conflicts may arise due to differing training histories and perspectives among professionals.
• Prioritizing the Client: In such conflicts, the behavior analyst must prioritize the best interest of the client.
• Recusal: It may be necessary to recuse oneself from a case if optimal service for the first party (client) cannot be provided while also aligning with the interests of the second party.

Documentation of Professional Activity

• Thematic Importance: Documentation is a recurring and vital theme in ethical practice, as highlighted by Standard $3.11$.
• Multiple Purposes of Documentation:
  • Continuity of Services: Ensures uninterrupted service delivery during interruptions (e.g., clinician illness for $10$ or $14$ days) by providing up-to-date information for a substitute provider.
  • Accountability: Demonstrates fulfillment of obligations and good work.
  • Self-Check: Helps behavior analysts monitor their own program implementation (e.g., "I haven't run the toothbrushing task analysis for the last $3$ days; I need to prioritize that.")
  • Supervisory Oversight: Supervisors rely on documentation to assess the accountability of their supervisees.
  • Legal or Organizational Requirements: Required for insurance-based services (specific session notes for reimbursement) and publicly funded agencies.
  • Timely Data-Based Decisions: Essential for effectiveness, ensuring behavior change in the desired direction, maintenance, and addressing arising issues.
• Client Access: All relevant documentation must be available to the client or their authorized representative.
• Confidentiality Limitations: When a third party is involved, confidentiality may need to be limited or information disclosed. This should be transparently communicated and ideally written into agreements or contracts.

Advocating for Appropriate Services

• Client-Centered Approach: Recommendations for service amounts must be practical and relative to the client's level of need.
• Guidelines and Resources:
  • CASP Guidelines: The Council of Autism Service Providers offers guidelines for determining intensive versus less intensive levels of service for autism (e.g., in a behavior assessment course).
  • Decision-Making Factors: Other factors also inform service level decisions.
• Realistic Goal Setting and Timelines:
  • Change Takes Time: Behavior changes require time and consistent application of services.
  • IEP Objectives Example: Setting realistic Individualized Education Plan (IEP) goals, such as learning $3$ new skills per quarter, should be informed by past progress but also achievable, allowing for revision if goals are met sooner.
  • Avoid Max-Level Services Unless Needed: Do not automatically provide the maximum authorized services if less is sufficient for progress, allowing clients time for other activities. However, if the maximum is needed for progress, it must be recommended and provided.
• Revisability of Plans: Despite being in writing, service plans are not immutable. They can and should be revised as needed, with all parties in agreement and documented changes.

Referrals

• When Necessary: Referrals are made when a client requires services beyond the behavior analyst's expertise.
• Example (Vision Impairment): A client with vision impairment needing community navigation skills was referred to a Teacher of the Visually Impaired (TVI). Subsequent collaboration between the BA and TVI ensured comprehensive skill training, combining street safety with task analysis for community interactions.
• Future Collaboration: The need for referrals often leads to interdisciplinary collaboration.

Discontinuing and Transitioning Services

• Continuity of Services: Behavior analysts do not abandon clients; rather, they facilitate the continuity of services. Plans are needed for both planned (e.g., vacation) and unplanned (e.g., emergency) absences.
  • Comprehensive Planning: This involves robust documentation, a clear technological plan for skill acquisition and behavior management, stakeholder involvement, and a "sub plan" or "maintenance binder" for individual client needs during absence.
• Conditions for Discontinuing Services: Services may be discontinued under specific conditions, which should be outlined and agreed upon in the service agreement prior to commencement:
  • Client has met all behavior change goals.
  • Client is no longer benefiting from the service.
  • The behavior analyst and/or supervisee are exposed to potentially harmful conditions that cannot be reasonably resolved (e.g., dangerous neighborhood requiring police escort or alternative service locations).
  • Client or stakeholder requests discontinuation (even if the behavior analyst disagrees with the decision).
  • Relevant stakeholders are not complying with the intervention, despite efforts to address barriers (e.g., revising plans to be practical, providing training and resources, or in cases of uncooperative school staff).
  • Funding is no longer available.
• Documentation for Discontinuation: These conditions should be clearly described in service agreements to provide a written, agreed-upon basis for the decision to discontinue services.
• Transitioning Services to Another Behavior Analyst: This occurs for various reasons:
  • Client moves out of the local service area.
  • Behavior analyst leaves the organization.
  • Client meets goals or requires different/lesser services outside the current BA's scope.
• Rigorous Transition Process:
  • Written Plan: A thorough, continuously reviewed written plan is essential.
  • Comprehensive Handoff: This includes observing and discussing each program, ensuring all data are summarized accessibly for the new provider, and providing necessary training.
  • Client Best Interest: The entire transition process prioritizes setting clients up for the best possible outcomes.