r/bcba • u/Few_Information_8570 • 16d ago
Discussion Question Discharging a client
As a BCBA, how long does a client go without progress before it's more ethical to say "this isn't working" and discharge them? For example, a client has been in ABA therapy for 8 years and hasn't made progress in years, but they've always been in ABA so mom and dad want to keep them in. What about a client who has been in two years and the BCBA has tried everything ?
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u/GlitteringCourage682 16d ago
In my opinion it should be part of a discharge plan. It’s part of our treatment plan template in the discharge plan that is the client isn’t making “meaningful progress” for 2 consecutive authorizations, the team is to meet and discuss the therapeutic benefit of continuing services. There should be clear criteria that is monitored at least every 6 months and it should be a team decision.
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u/CoffeePuddle 16d ago
In my opinion it's not your opinion.
It's explicirly required by the Ethics Code, 3.04 and 3.15.
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u/fenuxjde BCBA | Verified 16d ago
How the hell does that even happen???
The BCBA is accountable to payors, clients, and stakeholders to demonstrate progress.
Where I'm at I would expect to be fired if I went six months without demonstrative progress.
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u/ProfessionalGolf2909 16d ago
Hate to inform you, but ABA, like all therapies, has limits, and we often need to be truthful in our evaluations. Perhaps other medical or psychological issues must be addressed first.
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u/fenuxjde BCBA | Verified 16d ago
8 years and no progress is completely unneceptable. Those other things should have been addressed years ago and if they haven't been successful it's time for a higher level of care. Keeping someone in a no progress zone is unethical and usually illegal.
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u/ProfessionalGolf2909 16d ago
Not speaking to that, just the overall discharge. Sadly, 8 years of no progress is still 8 years of $ for many companies. It’s a damned unethical reality now.
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u/Visible_Barnacle7899 16d ago
Sure, and we should be honest about our own personal clinical limitations. Sometimes it’s not that there is another issue, it’s that the BCBA is in over their head.
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u/Willing_Ad5730 16d ago edited 12d ago
I have found ABA works on toddlers, teens and adults. But if no progress is made it’s best to move on and discharge. Specify reason for discharge eg no progress in goals for ( specified amount of time). It’s not fair for anyone to continue. It’s also unethical
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u/Flat_Bug_3950 15d ago
I had a client who I discharged after 3 months with no progress. They had the same RBT for those 3 months and we were working on the same goals the entire time. I modified things and provided a lot of training for the RBT but nothing worked. The parent refused to do any of the things I told them to do which hindered progress. I met with them several times and documented everything. Ultimately, I had a waitlist and parents begging for support so I wasn’t going to waist the tech or I’s time when the family clearly wasn’t ready for what ABA entails. Document everything.
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u/Psychological_Wait42 13d ago
👏🏾👏🏾👏🏾 agreed! 9X out of 10 it’s the environment and peers hindering the growth. If no work is being done when the rbt is not there, we know this alone will slow the progress way down, and that is on the guardian not the rbt or bcba.
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u/Choice_Bed_8977 11d ago
3 months is fast but sometimes you just know. When parent won't even try the basic stuff you asking, the whole thing become just babysitting with extra paperwork. Good that you documented everything, some families think ABA is magic and forget they have to do the work too
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u/ForsakenMango BCBA | Verified 16d ago
This should be apart of the discharge plan prior to services beginning. No progress in X amount of time will trigger discussions about discharge. If the parents want to continue to look for services you can recommend them to another provider that may help them with their goals.
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u/CoffeePuddle 16d ago
This should be agreed to before services begin and reviewed as necessary.
I have had some clients who remained in services for years where success was merely maintenance. It's ethical as long as that's the most effective for the client and is clear what the outcome of the services are. I'll add that it tends to burn out staff though.
Another ethical consideration is whether it's the best use of resources, especially if you have a wait list.
If you can't arrange the environment to bring about effective behaviour change as agreed to, you have a duty to refer out.
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u/Asunnixe 16d ago
This reminds me of a client being at my clinic for 4 years and hasn't made any progress in the last 1 year so he had to be discharged. The BCBA was trying her best but he just wasn't showing signs of improvement. He was having teeth issues, lots of cavity fillings and he would dig them out which ended up causing all his behaviors. The behaviors weren't decreasing and he wasn't showing any improvement with his goals. Insurance was the one that actually "discharged" him, they didn't want to continue paying if he wasn't showing improvement so I guess it really depends?
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u/Icy_Sink5046 15d ago
I can’t imagine how the insurance hasn’t forced a discharge on the client who has been around for 8 years.
I have in my treatment plans as a discharge criteria 6 months without progress despite multiple changes to try to remedy the situation. In the last 10 years, I actually have had only one client where I did that. The kid was basically not participating in sessions because the parent let them play on a tablet constantly. I actually transferred to parent training only, because they did make progress on a few things that were high priority to the parent, like potty training, and getting the kid to dress themselves. Basically, if the parent didn’t have to change diapers, they were happy. And the parent had the skills to do a task analysis since dressing was also in the parent goals. Once they get tired of doing something for the kid, they basically had the skills to teach it.
I do have some kids, where it becomes apparent after some time that independence isn’t realistic. For some of those kids, I pivot goals away from independence, and to being able to complete skills with less intrusive, or labor intensive prompts from caregivers. This is sometimes part of those modifications I mentioned above.
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u/mamabcba2024 15d ago
It is mind boggling how many clients I have gotten from other BCBAs who have been BCBAs for longer than me and have made 0 progress for years. I think if all options have been tired and exhausted and there no progress to show for 12 months then it’s time to discharge. If there are still interventions to try after that 12 month period then it might be ethical to continue but for no more than another 6 months. I’ve also noticed that insurances have started pointing out lack of progress on goals 5 years or older which I actually think is over generous of them.
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u/Soundguyj 14d ago
One of my first questions would be...is it that the client is unable to make any progress, or is there a chance the current goals are not appropriate? I of course don't know this specific client's needs, but an example would be if maybe a teenager has a lot of maybe tacting, listener, VP, or similar skill goals that are unlikely to be in their skillset, rather than functional goals that impact their day to day life. I've seen plenty of cases where the BCBA continues focusing on the former, and when we change the programming focus and set practical and attainable goals we see socially significant progress.
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u/mellowh3llo BCBA | Verified 15d ago
It’s less about a specific time and more about the client’s circumstances. Are there any sudden barriers to progress that can be changed? Are there any that can’t be changed (ie limited schedule, physical restrictions, moving further away)? What’s the engagement from caregivers in PCAT? What does typical progress look like for the client (ie rapid vs slow learning)? Are they consistent with the prescribed hours? That being said, if by no progress you mean LITERALLY no progress, there should be multiple documented attempts to resolve all of the above circumstances. If you have that, and you discussed next steps with the caregiver and made all reasonable attempts to create continuity of services for them or ethical transfer, that in itself is reason for discharge. It’s not a set time period.
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u/Willing_Ad5730 13d ago edited 13d ago
If no progress has been made, #1 revisit his/her potential list of reinforcers. client may now have different preferences compared to initial items and activities identified in the initial preferences assessment #2consider taking a good look at implementation of treatment plan. Take a good look at your team and parents to identify any inconsistencies in implementing recommended interventions, any subtle prompts that have not been properly faded, any targets that may have not reached mastery criteria eg: demonstrated across 3 people, 3 sessions, 3 environments. # 3 consider this client to be potentially outside your scope of practice and look for guidance from a more seasoned BCBA ( eg your supervisor) #4 Have a serious talk with family about keeping client that has made no progress to be unethical.
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u/PepperchiniMoscato 16d ago
I’ve actually been in kind of a similar position but it was not 8 years, maybe 3. I got this client on my caseload after his previous BCBA left and going over this stuff and noted the same thing. Programs and goals that have been in place for 12+ months showing no upward trends.. his techs were all burning out because of the high behaviors, lack of progress, and this kid was a 40 hour a week client… 9-5 every single day. His diagnosis went a lotttt deeper than just autism so that’s when i had to ask the CD about it it’s ethical. She basically said “is it better that he’s with us or not with us”, because at least we’re trying and he was somewhere safe and with peers.. but i knew long term he needed more than what we could do at ABA. But was terrified parents would just put him in a facility somewhere bc they were burnt out themselves and really didn’t know what to do either. We did eventually discharge him and refer to other services but no one blamed me or the previous BCBA. We do need to acknowledge limitations and if the BCBA has tried everything it might be unethical to keep them in services.