You’ve started ABA for your 5-year-old daughter in your home, every day for two hours after pre-k. Her behavior technician, Susan, seems young and doesn’t have any kids of her own, let alone any kids with special needs. You’re not sure about her at first. But in those first couple of weeks, you see your daughter open up with Susan in a way she has struggled to with so many people outside the family. Susan jumps off the couch and runs to the door as soon as the doorbell rings each afternoon. Susan can be calm and patient or bubbly, bright energy, and she knows exactly which version is needed in any given moment. You have watched her immediately respond to the BCBA’s feedback and guidance in sessions, and already your daughter is catching onto the learning goals from her treatment plan. A few months later, Susan is out sick for a day or two. Then out a few days two weeks after that. Then she seems to disappear entirely. The BCBA calls to tell you Susan put in her notice, effective immediately, but they’ll keep you updated on progress in finding a new technician. Wait–what? But you and your daughter don’t want a new technician. You want Susan. It’s only been a few months!

This is such a common story. I’ll admit that I myself have been that BCBA, nervously admitting to a family their technician has gone AWOL or will be moving on in a matter of weeks, trying to reassure them that we’re working diligently to find someone who can start ASAP.

CentralReach, one of the big data collection platforms in ABA, released a report this year on staff turnover, and the numbers are so much worse than many of us in the field even expected. For smaller operations, annual technician turnover is at about 77%. In other words, within a year, 3 in 4 technicians will quit ABA or at least go to another company. Annual turnover for mid-sized organizations is at 89%. For the large, multi-state companies, annual turnover is at about 103%. You might ask (as I first did) what >100% means in this context. It means that they lost staff, hired replacements, and lost replacements…all within a year.

So, just going off the data, if your daughter is with one of the “big guys” in the ABA space, Susan left, and Susan’s replacement is also probably leaving before your daughter’s first year of ABA is complete. It’s no wonder families are left feeling confused, frustrated, and skeptical, and staff are feeling much of the same.

Let’s shine a light on what you should know about behavior technician and RBT turnover (and what companies aren’t likely to tell you).

Not Just In It For the Money–But It Helps

When it comes to helping professions, there’s this pervasive expectation that pay shouldn’t matter and that you “shouldn’t be in it for the money.” I can honestly say that I have known no one in this field who was here for the money, regardless of what their pay or other benefits looked like. But there is no shame in needing and expecting a job that pays you a respectable rate and provides you with what you need to pay your bills.

Because therapy hours per ABA learner can vary and often are within a range of 10 to 30 hours per week, BTs and RBTs are often part-time employees. It can be challenging to Tetris a schedule together; for example, if your main client is Monday through Friday from 10:00 AM to 2:00 PM, based upon their availability, you will be scheduled for 20 hours per week and might have a hard time finding a client before 10:00 or after 2:00 in close enough proximity, not to mention if you personally have schedule conflicts, like college courses or a child to pick up from school. Even when BTs/RBTs are able to take an additional case or two to put them at around 40 hours per week, they may not qualify as full-time status. On top of this, drive time between clients, a low hourly pay in companies that may prioritize high profit margins and/or in states with low reimbursement rates, and frequent cancellations by the client family contribute to small and variable paychecks, even in comparison to other part-time and entry level jobs.

All of these factors increase the likelihood of BTs and RBTs in a company skewing younger, often in their 20s, when part-time work may be less detrimental to day-to-day life. These technicians may be completing college coursework in another field or otherwise preparing for more permanent careers in other paths, meaning they automatically may be unlikely to stay for longer than about a year.

You Will Get Bitten

I had a colleague who built this into her staff interviews. Her reasoning was pretty solid: “I would rather potential staff know what they might experience than just talk about the fun side of the job.”

You may not be bitten–in fact, I personally have been bitten only a handful of times in my years in ABA, and only by three learners I can think of. But you may be hit, kicked, tackled, headbutted, or spit on. Your hair may be pulled. You might have furniture, sharp objects, or bodily waste thrown at you. You might run after a child who moves very quickly and has had a lot of practice in eloping, or risk harm to yourself to block self-injurious behaviors, or be verbally threatened or berated. Even when practices are compassionate, neurodiversity affirming, supportive, gradual, and otherwise ethical and appropriate, severe behaviors can occur.

Staff may feel unsafe and unprepared in addition to facing potential injuries. I know of RBTs who have experienced concussions, having their front teeth knocked out, and gotten stitches. Another RBT found previously undiagnosed PTSD triggered by the physical and verbal aggression of a particular learner. Even the most emotionally developed and experienced staff can suffer from compassion fatigue, or emotional and physical depletion or exhaustion from the toll of caring professions.

What’s even worse, many companies do not understand the emotional impact, have the resources to provide resources, or, frankly, are invested enough to provide resources for part-time staff who may soon be out the door anyway.

With Supervisors Like These

The BT/RBT role is unique compared to a lot of other jobs in part because it requires frequent (weekly or more) direct, individual supervision, where a BCBA or another clinician reviews progress, provides training on how to teach new goals, provides feedback on current skills, and makes frequent changes to how skills are taught, what skills are prioritized, and more. BTs and RBTs have to be extremely flexible and willing to be watched and taught without shutting down guidance as judgment or insisting on what’s familiar, even if not the best thing at the time or on that case.

But some supervisors make this particularly challenging. More often than I would like to admit, supervisors can be disrespectful toward “lower level” staff, have harsh, vague, or unrealistic expectations, and can pass blame for lack of learner progress to BTs and RBTs. Part of this problem is systemic; BCBAs and other clinicians are often poorly trained before the role (fieldwork supervision and graduate-level courses) and once in the role, as well as being poorly overseen by a higher level of clinical leadership. They themselves can experience harsh, vague, unrealistic productivity expectations from company management. In my own experience as a clinician, I have seen myself start to drift into the same substandard supervisory practices when in an environment where I and my colleagues were treated with the same disregard, and, even while condemning these practices, I can empathize with other clinicians who experience the same.

So, while juggling the general demands of a role in ABA, a BT/RBT might also onboard under unsupportive and unclear conditions, be micromanaged or left without even minimum supervision requirements, be directed to implement ethically questionable or flat incorrect programming, and be expected to keep coming into an overall toxic work environment. In a field that can be tough enough, where compassion and support for one another can make all the difference, you have to ask yourself: with leaders like these, who needs enemies?

You Will Get Bitten: The Remix

We’ve covered a few of the challenges in working with learners with severe behaviors and working with less-than-helpful supervisors. Who is often also involved in an ABA treatment team?

It can be hard to go into a home and try to provide high-quality care when parents or others in the home create a stressful environment. This isn’t a criticism–parenting is stressful, and we can sometimes pass that stress around! Sometimes we will do things that we don’t even think about as being uncomfortable for another person, or we can so prioritize progress and our own expectations that we miss key barriers. Likely your ABA team, no matter the company, cares about your child and wants to make you happy as the caregiver, but miscommunication can get in the way of harmony and collaboration.

Sometimes self-professed “mama bears” (and similar family members) can have a sort of “bite” of their own! I have also had families insistent upon skills a learner was not yet ready for or were not able to be covered by insurance. This in itself is completely fine! I love talking to parents about why we target what we do and when, as well as what falls within the scope of ABA. But when this turns into anger and an unwillingness to discuss, this can stall progress and again impact collaboration. In some situations, parents will escalate this by asking the BT/RBT to do additional tasks than what is permitted by policy or what the staff member has been instructed to do, and this can be uncomfortable and put them in a predicament of risking upsetting the people whose home you’re in versus risking fraudulent practices.

In addition to the above, I have myself experienced family members being verbally aggressive, including yelling, swearing, accusing, threatening, and insulting. Parents fighting amongst themselves–especially if they try to pull in staff–can similarly increase tension. And in situations where BTs/RBTs are seemingly expected to also supervise and entertain younger siblings, the stress becomes the limitations to their focus on the learner, increased risk of unsafe behaviors if the learner becomes frustrated with the sibling, and the potential violation of many insurance payers’ requirements about focusing only on that specific learner’s medically necessary care.

Finally, other caregivers who may not be invested in ABA may reduce consistency both within and outside of sessions. I had a learner whose father, aunt, and grandparents had mostly equal caregiving responsibilities. The learner’s father was the only one to seek out and participate in ABA, while the aunt and each grandparent had their own ways of responding to undesired behaviors. With four potential consequences at any given time, this created a lot of instability–and sometimes, when the consequence didn’t serve the right function, actually contributed to the behaviors they were trying to decrease! The poor RBT sometimes felt uncomfortable reminding family members of their role and the necessity in only implementing what was part of the learner’s behavior plan, like when caregivers insisted on the RBT following their way and ignoring everyone else’s preferences.

Where From Here?

Being a BT or RBT is often considered an entry level job and, as such, one would expect professional growth opportunities. Some companies hire BTs and RBTs for recruiting, community outreach, and other administrative or operational roles. For some BTs/RBTs, bachelor- or master-level coursework in ABA in order to become a BCBA or BCaBA (Board-Certified Assistant Behavior Analyst) may be their chosen path, but this comes with thousands of fieldwork hours on top of that continued education and passing a very difficult board certification exam.

That’s if students can find adequate fieldwork opportunities. Some pay out of pocket (instead of being paid to do the work) for these. Even when built into a company’s structure, experience and growth in key performance areas can be unclear and lack actionable steps or hands-on learning to better develop these skills. This creates in turn lackluster supervisors, which again perpetuates the BT/RBT turnover, as described above.

Turnover Takeover

The final reason here is to the point: when you’re surrounded by turnover, you’re probably going to be quick to leave too.

What is From the Nest Doing?

No ABA provider can be perfect, but by making intentional choices, designed to support staff while maintaining client care and what we know to be ethically and scientifically right, we can make continual efforts to be a company BT/RBTs want to work for–and stay with.

As a show of respect, From the Nest pays direct care staff a higher hourly pay compared to even the big companies. We view BTs and RBTs as fellow clinicians and professionals, not as entry level. Starting pay is standardized to account for education, relevant experience (even outside of ABA, like childcare, special education, and psychology), and certification, and staff are able to request a pay reassess at any time in order to meet with leadership to determine if they qualify based on these metrics or what specific, achievable goals are needed to advance. Annual raises are also up to 5% based on performance, which is greater than the industry standard 3%.

We maintain expectations for both staff and families. This is not to say there is no flexibility, but inability for either party to meet criteria is an opportunity to work together to overcome barriers to success. What do family expectations have to do with staff retention? Because inappropriate behavior, no-shows and frequent cancellations, and regularly ignoring professional and ethical boundaries can burn our A-team out! We expect our staff to show your family the utmost respect, and in return, we do not tolerate anything less than respect toward our team members.

From the Nest continually reassesses if we can safely support a learner and their family, as well as how to better support individual technicians based upon the complexities of individual cases. We have recurring 1:1 check-ins between staff and me, the owner, so that we can find pain points before they burn someone out and we can help staff to set objective, measurable goals for themselves. We prioritize heavy onboarding, increased supervision, and strong clinician oversight with the intention of BTs and RBTs feeling well-trained and well-supported at every step. We expect informed compassionate care from the top down so no one is pouring from an empty bucket.

From the Nest is already looking to the future to find even more ways to take care of our team members. A few potential future initiatives we’re exploring are a revenue-based bonus structure for all staff (to reward their individual contributions to company-level success), healthcare stipends for full-time staff, attendance incentives, BT/RBT community liaisons as an additional paid opportunity when between clients, and increased access to mental health resources through community providers. We are also partnered with other clinician-owned, clinician-managed practices, which enables us to learn even more ways ABA providers are reinforcing their staff. Stay tuned to see how we grow and help to shape what ABA can be!

by Britt Bolton, owner/lead BCBA