WEBVTT
00:00:06.160 --> 00:00:09.599
Welcome to another episode of MI for Change.
00:00:10.080 --> 00:00:18.320
And today I want to speak to those agency owners, those clinical directors, even those supervising oversight BCBAs.
00:00:18.800 --> 00:00:27.280
There's a moment that happens in almost every ABA clinic, every ABA agency, and it usually isn't dramatic.
00:00:27.440 --> 00:00:31.519
There's no crisis, there's no emergency, no major behavior escalation.
00:00:32.159 --> 00:00:45.679
Instead, you are sitting at a table, at a desk, at a conference room in a case review, and you're sitting with your clinical team looking at graphs that have been slowly flattening over the last several months.
00:00:45.920 --> 00:00:47.679
The child has made progress.
00:00:47.840 --> 00:00:51.280
They're requesting more, they're tolerating transitions better.
00:00:51.439 --> 00:00:54.399
They're responding to prompts more independently.
00:00:54.560 --> 00:00:56.719
Everything seems to be going great.
00:00:56.960 --> 00:00:59.119
But then you notice something.
00:00:59.759 --> 00:01:05.280
Every goal that depends on what happens outside of therapy has barely moved.
00:01:05.599 --> 00:01:10.879
There's really not a lot of parent training or parent coaching sessions being done.
00:01:11.120 --> 00:01:12.799
You don't see it built.
00:01:13.120 --> 00:01:22.239
The bedtime routine, independent dressing, generalizing communication with parents, following routines without the therapist present.
00:01:22.640 --> 00:01:26.319
Months after months, the graph barely moves.
00:01:26.400 --> 00:01:27.760
It barely changes.
00:01:28.000 --> 00:01:34.400
If you're like most clinicians, your first thought is, well, maybe we need to modify the intervention.
00:01:34.560 --> 00:01:36.959
Maybe we need to change just so it works.
00:01:37.200 --> 00:01:42.239
Maybe the prompting hierarchy needs adjustment, or maybe the reinforcement needs to change.
00:01:42.480 --> 00:01:44.640
Maybe the goals are too difficult.
00:01:45.120 --> 00:01:47.680
And sometimes that is totally true.
00:01:48.000 --> 00:01:53.120
But other times the data is pointing somewhere else entirely.
00:01:53.359 --> 00:02:00.959
I remember reviewing a case with one of my supervisors where a child was making beautiful progress during therapy sessions.
00:02:01.120 --> 00:02:08.879
Every therapist who worked with him reported success, treatment integrity was high, IOA was high.
00:02:09.120 --> 00:02:17.360
The programs I thought were solid, and the data actually looked great until we looked at the goals that depended on the caregiver.
00:02:18.240 --> 00:02:21.199
Those hadn't changed for months.
00:02:21.520 --> 00:02:28.879
When we stepped back and asked what was different between therapy and home, the answer became obvious.
00:02:29.120 --> 00:02:32.879
The intervention wasn't really breaking down, implementation was.
00:02:33.280 --> 00:02:37.840
That conversation completely changed how we viewed the case.
00:02:38.080 --> 00:02:41.680
And it's exactly what today's episode is about.
00:02:42.000 --> 00:02:44.400
I'm sure this resonates with a lot of you.
00:02:44.560 --> 00:03:00.879
A lot of you who have been frustrated, breaking your heads, trying to understand why this is not happening, why this parent training session is not effective, or why it seems like it's not going anywhere and it's not generalizing.
00:03:01.840 --> 00:03:05.360
Let's talk about what the data is actually measuring.
00:03:05.599 --> 00:03:10.159
As behavior analysts, as behavior scientists, we love data.
00:03:10.400 --> 00:03:13.120
It's one of the things that makes our field unique.
00:03:13.280 --> 00:03:16.960
I always say this during our orientations with new clinicians.
00:03:17.120 --> 00:03:21.759
One of the things that puts us apart from other fields is that we're always taking data.
00:03:22.000 --> 00:03:23.680
We're literally taking data.
00:03:23.919 --> 00:03:25.280
We are scientists.
00:03:25.439 --> 00:03:26.639
That's who we are.
00:03:27.520 --> 00:03:29.840
We don't rely on intuition alone.
00:03:30.080 --> 00:03:41.840
We collect data, we graph behavior, we analyze trends, we look at different levels, at slopes, at variability, and we make decisions based on evidence.
00:03:42.479 --> 00:03:46.319
But here's the question I want to ask you today.
00:03:46.639 --> 00:03:52.319
When progress stalls, what's the very first variable we investigate?
00:03:52.479 --> 00:03:55.680
Most of us immediately look at the intervention.
00:03:55.919 --> 00:03:57.680
Did we choose the right goal?
00:03:58.000 --> 00:04:01.680
Did we need a different prompting strategy?
00:04:01.840 --> 00:04:04.080
Should reinforcement be adjusted?
00:04:04.319 --> 00:04:06.639
Do we have the right function for the behaviors?
00:04:06.719 --> 00:04:08.000
And these are excellent questions.
00:04:08.080 --> 00:04:10.960
These are questions that we ask ourselves all the time.
00:04:11.199 --> 00:04:16.079
But there's another variable that often receives far less attention.
00:04:16.319 --> 00:04:20.240
The person spending the most time with a child, the parent.
00:04:20.480 --> 00:04:21.199
Think about it.
00:04:21.279 --> 00:04:26.639
This is one of those extraneous variables that we try very much to control.
00:04:27.519 --> 00:04:37.040
Even families receive 20 hours of ABA each week and they still spend well over 100 hours outside of therapy with the child.
00:04:37.279 --> 00:04:38.800
That's where life happens.
00:04:38.879 --> 00:04:40.480
That's where routines happen.
00:04:40.560 --> 00:04:42.800
That's where communication is practiced.
00:04:42.959 --> 00:04:46.720
That's where behaviors either generalize or they don't.
00:04:46.959 --> 00:05:00.160
And if a child demonstrates a skill beautifully with one therapist or with his mate therapist, but never demonstrates it at home, the data isn't necessarily telling you the intervention failed.
00:05:00.399 --> 00:05:05.680
The data may be telling you that generalization never had the opportunity to occur.
00:05:05.920 --> 00:05:10.639
And I think that's such an important concept to focus on.
00:05:11.519 --> 00:05:16.000
Generalization never had the opportunity to occur.
00:05:16.319 --> 00:05:21.120
We failed to contrive that outside of our therapy session with the parent.
00:05:21.439 --> 00:05:24.480
And those are two very different clinical problems.
00:05:24.800 --> 00:05:28.639
And they also require two very different solutions.
00:05:30.319 --> 00:05:38.000
So, one thing that agencies, private practices, clinics, however you want to call them, don't usually audit for.
00:05:38.480 --> 00:05:47.680
And I want to speak directly to agency owners and those clinical directors because this is where individual cases become organizational patterns.
00:05:47.920 --> 00:05:53.759
Most agencies regularly audit documents, more so if you're working with Medicaid.
00:05:54.319 --> 00:06:05.120
We audit treatment plans, supervision ratios, billing compliance authorizations, treatment integrity, and all these things are incredibly important.
00:06:05.279 --> 00:06:10.160
But here's something I've rarely seen agencies consistently measure.
00:06:10.480 --> 00:06:17.199
How often are stalled cases also cases where parent implementation is inconsistent?
00:06:17.439 --> 00:06:24.240
Imagine reviewing every case that has remained open for a very long time or longer than what you expected.
00:06:24.399 --> 00:06:32.000
And instead of only asking, what should the clinician change, that you ask, what do we know about parent implementation?
00:06:32.319 --> 00:06:43.920
Not whether parent training occurred, not whether signatures were collected, not whether the BCBA documented a meeting, but whether meaningful behavior change was happening with a caregiver.
00:06:44.240 --> 00:07:00.399
I remember having a conversation with the leadership team after noticing several long-term cases were have similar patterns, different clinicians, different kids, different diagnoses, different treatment plans, yet we had the same outcome.
00:07:00.639 --> 00:07:06.240
We had excellent progress during our sessions, minimal progress outside of them.
00:07:06.399 --> 00:07:08.959
When we look deeper, we realized something.
00:07:09.199 --> 00:07:12.399
Parent coaching wasn't actually part of the treatment.
00:07:12.639 --> 00:07:17.600
It was something that happened at the end of the supervision, if there was time left.
00:07:17.920 --> 00:07:27.920
And we know very well that this is a pattern that we get stuck in because I've spoken with a lot of our BCBAs and other agencies that I do consultations for.
00:07:28.160 --> 00:07:29.600
And this is a trend.
00:07:29.759 --> 00:07:31.759
This is something that we are used to doing.
00:07:31.920 --> 00:07:38.720
We do supervision or parent coaching sessions or whatever we want to call it right at the end of our supervision session.
00:07:38.800 --> 00:07:39.680
We're already at home.
00:07:39.759 --> 00:07:40.959
The parent is already there.
00:07:41.120 --> 00:07:42.480
And what happens?
00:07:42.720 --> 00:07:44.160
Well, it's rushed.
00:07:44.319 --> 00:07:45.040
What happens?
00:07:45.120 --> 00:07:46.079
We leave things out.
00:07:46.160 --> 00:07:47.519
It's not about the caregiver.
00:07:47.839 --> 00:07:51.199
It becomes about the treatment team and everything else.
00:07:53.120 --> 00:08:01.040
That realization really shifted my entire perspective because, again, it's not a clinical problem.
00:08:01.279 --> 00:08:03.040
It's not a family problem.
00:08:03.360 --> 00:08:06.079
It's actually a system problem.
00:08:06.319 --> 00:08:10.879
And if you own an organization, you know how important these systems are.
00:08:11.519 --> 00:08:23.199
So organizations don't unintentionally build a clinical model around treating children with equally investing and changing those caregiver behaviors.
00:08:23.439 --> 00:08:26.720
Both things have to be present at the same time.
00:08:28.160 --> 00:08:35.759
A case that stalls because parent implementation isn't happening stays open longer.
00:08:35.919 --> 00:08:46.559
It requires additional supervision, more treatment planning, more reassessment, more clinical hours, more, more, more frustration from everyone.
00:08:46.799 --> 00:08:51.039
Families also begin wondering whether therapy is actually working.
00:08:51.279 --> 00:08:55.440
Clinicians begin questioning themselves am I a good clinician?
00:08:55.600 --> 00:08:56.639
What's going on?
00:08:56.879 --> 00:09:05.759
And supervisors spend an increasing amount of time troubleshooting, which ends up giving us so much burnout.
00:09:06.000 --> 00:09:09.759
Everyone works harder, but outcomes don't necessarily improve.
00:09:09.919 --> 00:09:11.120
They don't change.
00:09:11.519 --> 00:09:13.759
Now compare that with another case.
00:09:13.919 --> 00:09:27.600
The parent actively participates, they ask questions, they practice between sessions, they troubleshoot obstacles with their VCBA, and then the child begins demonstrating skills across environments.
00:09:27.840 --> 00:09:34.399
Generalization improves, prompts fade, goals close, services eventually decrease.
00:09:35.279 --> 00:09:40.960
That's not just a better clinical outcome, it's a healthier operational outcome.
00:09:41.200 --> 00:09:42.559
And it's ethical.
00:09:42.879 --> 00:09:46.320
If we look at our ethics, that's exactly what we strive for.
00:09:46.559 --> 00:09:51.519
Successful discharges create capacity for new families to come in.
00:09:51.759 --> 00:09:57.679
They also, speaking about it in a business sense, create more referrals.
00:09:58.480 --> 00:10:03.440
Clinicians experience more meaningful success in what they've done in their work.
00:10:03.600 --> 00:10:07.600
And parents feel empowered instead of dependent on the therapist.
00:10:08.080 --> 00:10:10.240
And the child gains independence.
00:10:10.399 --> 00:10:11.519
Everyone wins.
00:10:11.840 --> 00:10:17.120
So this is why I believe parent fall through isn't simply another treatment variable.
00:10:17.200 --> 00:10:21.200
It's one of the strongest predictors of long-term success.
00:10:21.440 --> 00:10:34.799
And perhaps more importantly, it's something we can influence, not by giving longer lectures, not by sending more handouts, but really by becoming better at partnering up with parents.
00:10:35.120 --> 00:10:39.360
Because parents don't need us to convince them, they already know.
00:10:39.519 --> 00:10:43.840
They need us to understand what's standing between them and the implementation.
00:10:44.159 --> 00:10:46.879
And I want that to drive home with you.
00:10:47.120 --> 00:10:49.120
That's what they really need.
00:10:49.440 --> 00:10:59.840
That's their, that should be the goal of that parent training session, figuring out and trying to understand what is standing in the way of the implementation.
00:11:00.879 --> 00:11:06.159
I had a session with one of my BCBAs last week.
00:11:06.399 --> 00:11:16.480
And I remember her telling me, well, you know, the funny thing about this parent is that this parent, when we meet, she tells me, yes, I'm going to implement this.
00:11:16.639 --> 00:11:18.480
She's like, I totally understand it.
00:11:18.559 --> 00:11:19.679
She repeats it back to me.
00:11:19.840 --> 00:11:23.120
I use the AOA approach that you've taught me.
00:11:23.360 --> 00:11:26.720
Everything seems to work, but she doesn't.
00:11:26.879 --> 00:11:28.080
She just doesn't do it.
00:11:28.240 --> 00:11:31.440
And this therapist was very, very stuck.
00:11:31.600 --> 00:11:32.480
She felt very stuck.
00:11:32.559 --> 00:11:34.159
She felt very frustrated.
00:11:34.320 --> 00:11:37.200
And she was coming to me because she was like, I just don't get it.
00:11:37.360 --> 00:11:38.720
What should I do differently?
00:11:39.840 --> 00:11:42.320
And I told her something very simple.
00:11:42.480 --> 00:11:51.279
And I said, Have you asked her very directly and very nicely, what's standing in the way of her implementing this?
00:11:51.679 --> 00:11:56.159
Because you've seen that she knows the concept.
00:11:56.320 --> 00:11:59.440
You've told her about the concept, but it's not happening.
00:11:59.679 --> 00:12:00.559
She's like, you know what?
00:12:00.720 --> 00:12:02.320
Now that you mention it, I haven't.
00:12:02.480 --> 00:12:04.159
And sometimes we don't think about these things.
00:12:04.240 --> 00:12:05.519
You're not that salient.
00:12:05.679 --> 00:12:08.960
And then she told me, Well, how can I ask her in a nice way?
00:12:09.120 --> 00:12:12.639
And I said, Well, why would it be a rough way?
00:12:12.799 --> 00:12:14.879
Why would we want to ask her in a rough way?
00:12:15.039 --> 00:12:16.639
This is just a general question.
00:12:16.720 --> 00:12:25.200
I would say something like, hey, mom, I've noticed that we've spoken about this intervention and you tell me that you're going to implement it and you understand it.
00:12:25.440 --> 00:12:29.519
I'm kind of curious when we go to sessions, I don't see you doing this.
00:12:29.600 --> 00:12:33.679
And I really want to understand because I want to work with you on this.
00:12:33.840 --> 00:12:38.240
So what do you think is standing in the way of you implementing this successfully?
00:12:38.559 --> 00:12:38.879
See?
00:12:39.759 --> 00:12:40.799
No roughness.
00:12:40.960 --> 00:12:43.519
I don't think the parent will take it the wrong way.
00:12:43.679 --> 00:12:46.480
And we were very honest with our question.
00:12:47.600 --> 00:12:50.639
So here's my invitation this week for you guys.
00:12:50.879 --> 00:13:01.919
Whether you're managing one caseload or overseeing 70 clinicians, choose three cases that have remained open longer than expected.
00:13:02.080 --> 00:13:06.799
Look at the graphs, look at the treatment goals, and then ask one additional question.
00:13:07.039 --> 00:13:11.039
What do we actually know about caregiver implementation?
00:13:11.440 --> 00:13:16.639
Not what was documented, not how many parent training sessions occurred.
00:13:16.879 --> 00:13:22.879
What evidence do we have that new caregiver behaviors are occurring consistently at home?
00:13:23.120 --> 00:13:25.360
I think you'll discover something important.
00:13:25.600 --> 00:13:32.799
Many of the patterns we attribute to difficult cases are actually opportunities to really strengthen that parent partnership.
00:13:32.960 --> 00:13:38.480
And that's really encouraging because caregiver behavior is something we can support.
00:13:38.960 --> 00:13:47.759
And if you'd like one practical framework for having these conversations, I've included my free ask offer ask guide in the show notes.
00:13:47.840 --> 00:13:55.279
It's simple, it's structured, and it's something you can begin using during your next parent meeting or supervision sessions.
00:13:55.519 --> 00:13:57.679
I hope you all enjoyed this.
00:13:57.919 --> 00:14:08.879
Of course, if you find it valuable, send it to another clinician, send it to another BCBA, BCABA, RBT psychologist, whoever you think needs to hear this.
00:14:09.120 --> 00:14:11.039
I'll see you in the next episode.
00:14:12.399 --> 00:14:16.399
Thank you for joining me on today's episode of MI for Change.
00:14:16.799 --> 00:14:31.200
If you're ready to keep growing your motivational interviewing skills, I'd love to invite you to explore my MI Academy, where you'll find a full library of on demand courses designed to help you put MI into practice with confidence.
00:14:31.440 --> 00:14:38.080
You can learn more at www.drmonicagilbert.com.
00:14:38.320 --> 00:14:42.639
Until next time, keep asking the questions that spark change.
00:00:06.160 --> 00:00:09.599
Welcome to another episode of MI for Change.
00:00:10.080 --> 00:00:18.320
And today I want to speak to those agency owners, those clinical directors, even those supervising oversight BCBAs.
00:00:18.800 --> 00:00:27.280
There's a moment that happens in almost every ABA clinic, every ABA agency, and it usually isn't dramatic.
00:00:27.440 --> 00:00:31.519
There's no crisis, there's no emergency, no major behavior escalation.
00:00:32.159 --> 00:00:45.679
Instead, you are sitting at a table, at a desk, at a conference room in a case review, and you're sitting with your clinical team looking at graphs that have been slowly flattening over the last several months.
00:00:45.920 --> 00:00:47.679
The child has made progress.
00:00:47.840 --> 00:00:51.280
They're requesting more, they're tolerating transitions better.
00:00:51.439 --> 00:00:54.399
They're responding to prompts more independently.
00:00:54.560 --> 00:00:56.719
Everything seems to be going great.
00:00:56.960 --> 00:00:59.119
But then you notice something.
00:00:59.759 --> 00:01:05.280
Every goal that depends on what happens outside of therapy has barely moved.
00:01:05.599 --> 00:01:10.879
There's really not a lot of parent training or parent coaching sessions being done.
00:01:11.120 --> 00:01:12.799
You don't see it built.
00:01:13.120 --> 00:01:22.239
The bedtime routine, independent dressing, generalizing communication with parents, following routines without the therapist present.
00:01:22.640 --> 00:01:26.319
Months after months, the graph barely moves.
00:01:26.400 --> 00:01:27.760
It barely changes.
00:01:28.000 --> 00:01:34.400
If you're like most clinicians, your first thought is, well, maybe we need to modify the intervention.
00:01:34.560 --> 00:01:36.959
Maybe we need to change just so it works.
00:01:37.200 --> 00:01:42.239
Maybe the prompting hierarchy needs adjustment, or maybe the reinforcement needs to change.
00:01:42.480 --> 00:01:44.640
Maybe the goals are too difficult.
00:01:45.120 --> 00:01:47.680
And sometimes that is totally true.
00:01:48.000 --> 00:01:53.120
But other times the data is pointing somewhere else entirely.
00:01:53.359 --> 00:02:00.959
I remember reviewing a case with one of my supervisors where a child was making beautiful progress during therapy sessions.
00:02:01.120 --> 00:02:08.879
Every therapist who worked with him reported success, treatment integrity was high, IOA was high.
00:02:09.120 --> 00:02:17.360
The programs I thought were solid, and the data actually looked great until we looked at the goals that depended on the caregiver.
00:02:18.240 --> 00:02:21.199
Those hadn't changed for months.
00:02:21.520 --> 00:02:28.879
When we stepped back and asked what was different between therapy and home, the answer became obvious.
00:02:29.120 --> 00:02:32.879
The intervention wasn't really breaking down, implementation was.
00:02:33.280 --> 00:02:37.840
That conversation completely changed how we viewed the case.
00:02:38.080 --> 00:02:41.680
And it's exactly what today's episode is about.
00:02:42.000 --> 00:02:44.400
I'm sure this resonates with a lot of you.
00:02:44.560 --> 00:03:00.879
A lot of you who have been frustrated, breaking your heads, trying to understand why this is not happening, why this parent training session is not effective, or why it seems like it's not going anywhere and it's not generalizing.
00:03:01.840 --> 00:03:05.360
Let's talk about what the data is actually measuring.
00:03:05.599 --> 00:03:10.159
As behavior analysts, as behavior scientists, we love data.
00:03:10.400 --> 00:03:13.120
It's one of the things that makes our field unique.
00:03:13.280 --> 00:03:16.960
I always say this during our orientations with new clinicians.
00:03:17.120 --> 00:03:21.759
One of the things that puts us apart from other fields is that we're always taking data.
00:03:22.000 --> 00:03:23.680
We're literally taking data.
00:03:23.919 --> 00:03:25.280
We are scientists.
00:03:25.439 --> 00:03:26.639
That's who we are.
00:03:27.520 --> 00:03:29.840
We don't rely on intuition alone.
00:03:30.080 --> 00:03:41.840
We collect data, we graph behavior, we analyze trends, we look at different levels, at slopes, at variability, and we make decisions based on evidence.
00:03:42.479 --> 00:03:46.319
But here's the question I want to ask you today.
00:03:46.639 --> 00:03:52.319
When progress stalls, what's the very first variable we investigate?
00:03:52.479 --> 00:03:55.680
Most of us immediately look at the intervention.
00:03:55.919 --> 00:03:57.680
Did we choose the right goal?
00:03:58.000 --> 00:04:01.680
Did we need a different prompting strategy?
00:04:01.840 --> 00:04:04.080
Should reinforcement be adjusted?
00:04:04.319 --> 00:04:06.639
Do we have the right function for the behaviors?
00:04:06.719 --> 00:04:08.000
And these are excellent questions.
00:04:08.080 --> 00:04:10.960
These are questions that we ask ourselves all the time.
00:04:11.199 --> 00:04:16.079
But there's another variable that often receives far less attention.
00:04:16.319 --> 00:04:20.240
The person spending the most time with a child, the parent.
00:04:20.480 --> 00:04:21.199
Think about it.
00:04:21.279 --> 00:04:26.639
This is one of those extraneous variables that we try very much to control.
00:04:27.519 --> 00:04:37.040
Even families receive 20 hours of ABA each week and they still spend well over 100 hours outside of therapy with the child.
00:04:37.279 --> 00:04:38.800
That's where life happens.
00:04:38.879 --> 00:04:40.480
That's where routines happen.
00:04:40.560 --> 00:04:42.800
That's where communication is practiced.
00:04:42.959 --> 00:04:46.720
That's where behaviors either generalize or they don't.
00:04:46.959 --> 00:05:00.160
And if a child demonstrates a skill beautifully with one therapist or with his mate therapist, but never demonstrates it at home, the data isn't necessarily telling you the intervention failed.
00:05:00.399 --> 00:05:05.680
The data may be telling you that generalization never had the opportunity to occur.
00:05:05.920 --> 00:05:10.639
And I think that's such an important concept to focus on.
00:05:11.519 --> 00:05:16.000
Generalization never had the opportunity to occur.
00:05:16.319 --> 00:05:21.120
We failed to contrive that outside of our therapy session with the parent.
00:05:21.439 --> 00:05:24.480
And those are two very different clinical problems.
00:05:24.800 --> 00:05:28.639
And they also require two very different solutions.
00:05:30.319 --> 00:05:38.000
So, one thing that agencies, private practices, clinics, however you want to call them, don't usually audit for.
00:05:38.480 --> 00:05:47.680
And I want to speak directly to agency owners and those clinical directors because this is where individual cases become organizational patterns.
00:05:47.920 --> 00:05:53.759
Most agencies regularly audit documents, more so if you're working with Medicaid.
00:05:54.319 --> 00:06:05.120
We audit treatment plans, supervision ratios, billing compliance authorizations, treatment integrity, and all these things are incredibly important.
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But here's something I've rarely seen agencies consistently measure.
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How often are stalled cases also cases where parent implementation is inconsistent?
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Imagine reviewing every case that has remained open for a very long time or longer than what you expected.
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And instead of only asking, what should the clinician change, that you ask, what do we know about parent implementation?
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Not whether parent training occurred, not whether signatures were collected, not whether the BCBA documented a meeting, but whether meaningful behavior change was happening with a caregiver.
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I remember having a conversation with the leadership team after noticing several long-term cases were have similar patterns, different clinicians, different kids, different diagnoses, different treatment plans, yet we had the same outcome.
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We had excellent progress during our sessions, minimal progress outside of them.
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When we look deeper, we realized something.
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Parent coaching wasn't actually part of the treatment.
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It was something that happened at the end of the supervision, if there was time left.
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And we know very well that this is a pattern that we get stuck in because I've spoken with a lot of our BCBAs and other agencies that I do consultations for.
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And this is a trend.
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This is something that we are used to doing.
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We do supervision or parent coaching sessions or whatever we want to call it right at the end of our supervision session.
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We're already at home.
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The parent is already there.
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And what happens?
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Well, it's rushed.
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What happens?
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We leave things out.
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It's not about the caregiver.
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It becomes about the treatment team and everything else.
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That realization really shifted my entire perspective because, again, it's not a clinical problem.
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It's not a family problem.
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It's actually a system problem.
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And if you own an organization, you know how important these systems are.
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So organizations don't unintentionally build a clinical model around treating children with equally investing and changing those caregiver behaviors.
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Both things have to be present at the same time.
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A case that stalls because parent implementation isn't happening stays open longer.
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It requires additional supervision, more treatment planning, more reassessment, more clinical hours, more, more, more frustration from everyone.
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Families also begin wondering whether therapy is actually working.
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Clinicians begin questioning themselves am I a good clinician?
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What's going on?
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And supervisors spend an increasing amount of time troubleshooting, which ends up giving us so much burnout.
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Everyone works harder, but outcomes don't necessarily improve.
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They don't change.
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Now compare that with another case.
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The parent actively participates, they ask questions, they practice between sessions, they troubleshoot obstacles with their VCBA, and then the child begins demonstrating skills across environments.
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Generalization improves, prompts fade, goals close, services eventually decrease.
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That's not just a better clinical outcome, it's a healthier operational outcome.
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And it's ethical.
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If we look at our ethics, that's exactly what we strive for.
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Successful discharges create capacity for new families to come in.
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They also, speaking about it in a business sense, create more referrals.
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Clinicians experience more meaningful success in what they've done in their work.
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And parents feel empowered instead of dependent on the therapist.
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And the child gains independence.
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Everyone wins.
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So this is why I believe parent fall through isn't simply another treatment variable.
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It's one of the strongest predictors of long-term success.
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And perhaps more importantly, it's something we can influence, not by giving longer lectures, not by sending more handouts, but really by becoming better at partnering up with parents.
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Because parents don't need us to convince them, they already know.
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They need us to understand what's standing between them and the implementation.
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And I want that to drive home with you.
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That's what they really need.
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That's their, that should be the goal of that parent training session, figuring out and trying to understand what is standing in the way of the implementation.
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I had a session with one of my BCBAs last week.
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And I remember her telling me, well, you know, the funny thing about this parent is that this parent, when we meet, she tells me, yes, I'm going to implement this.
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She's like, I totally understand it.
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She repeats it back to me.
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I use the AOA approach that you've taught me.
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Everything seems to work, but she doesn't.
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She just doesn't do it.
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And this therapist was very, very stuck.
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She felt very stuck.
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She felt very frustrated.
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And she was coming to me because she was like, I just don't get it.
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What should I do differently?
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And I told her something very simple.
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And I said, Have you asked her very directly and very nicely, what's standing in the way of her implementing this?
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Because you've seen that she knows the concept.
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You've told her about the concept, but it's not happening.
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She's like, you know what?
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Now that you mention it, I haven't.
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And sometimes we don't think about these things.
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You're not that salient.
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And then she told me, Well, how can I ask her in a nice way?
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And I said, Well, why would it be a rough way?
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Why would we want to ask her in a rough way?
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This is just a general question.
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I would say something like, hey, mom, I've noticed that we've spoken about this intervention and you tell me that you're going to implement it and you understand it.
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I'm kind of curious when we go to sessions, I don't see you doing this.
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And I really want to understand because I want to work with you on this.
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So what do you think is standing in the way of you implementing this successfully?
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See?
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No roughness.
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I don't think the parent will take it the wrong way.
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And we were very honest with our question.
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So here's my invitation this week for you guys.
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Whether you're managing one caseload or overseeing 70 clinicians, choose three cases that have remained open longer than expected.
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Look at the graphs, look at the treatment goals, and then ask one additional question.
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What do we actually know about caregiver implementation?
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Not what was documented, not how many parent training sessions occurred.
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What evidence do we have that new caregiver behaviors are occurring consistently at home?
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I think you'll discover something important.
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Many of the patterns we attribute to difficult cases are actually opportunities to really strengthen that parent partnership.
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And that's really encouraging because caregiver behavior is something we can support.
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And if you'd like one practical framework for having these conversations, I've included my free ask offer ask guide in the show notes.
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It's simple, it's structured, and it's something you can begin using during your next parent meeting or supervision sessions.
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I hope you all enjoyed this.
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Of course, if you find it valuable, send it to another clinician, send it to another BCBA, BCABA, RBT psychologist, whoever you think needs to hear this.
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I'll see you in the next episode.
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Thank you for joining me on today's episode of MI for Change.
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If you're ready to keep growing your motivational interviewing skills, I'd love to invite you to explore my MI Academy, where you'll find a full library of on demand courses designed to help you put MI into practice with confidence.
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You can learn more at www.drmonicagilbert.com.
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Until next time, keep asking the questions that spark change.
