By Matt Harrington, BCBA · Behaviorist Book Club · Research-backed answers for behavior analysts
Multiple strategies can facilitate participation for individuals who do not use verbal communication as their primary modality. Systematic preference assessments — including paired stimulus, multiple stimulus without replacement, and free operant observation — identify preferred items, activities, and conditions that can inform goal selection and reinforcement system design. Choice-making opportunities embedded throughout the day allow clients to express preferences in real time. Visual schedules with choice points give clients control over aspects of their daily routine. AAC devices, picture boards, and other alternative communication systems can be programmed with options relevant to care planning. Observational assessment of engagement and affect during different activities provides indirect evidence of preferences. Structured trials presenting options for goals or activities and recording the client's selection, approach, or avoidance behavior provide systematic preference data. The key principle is that communication limitations do not eliminate preferences — they require the behavior analyst to be more creative and systematic in identifying and incorporating those preferences.
Several provisions of the Ethics Code address client participation directly and indirectly. Code 2.09 requires involving clients and relevant stakeholders in treatment plan development. Code 4.07 affirms the client's right to make choices regarding their treatment. Code 2.01 emphasizes the right to effective treatment, which includes treatment that is socially valid — meaningful and acceptable from the client's perspective. Code 2.15 requires minimizing risk, which is supported by client input that helps identify procedures the client finds aversive or inappropriate. Taken together, these provisions create a clear mandate for systematic client participation that goes beyond token inclusion. The behavior analyst is expected to create genuine opportunities for clients to influence the goals, methods, and evaluation of their own treatment, adapted to their communication and cognitive abilities.
Conflicts between client preferences and clinical judgment should be approached with a presumption in favor of client autonomy. The first step is to ensure you fully understand the client's preference — is it a genuine, stable preference or a momentary response? The second step is to examine whether your clinical judgment is based on evidence or on professional assumptions about what the client 'should' want. The third step is to explore creative solutions that honor the client's preference while addressing your clinical concern. When genuine conflicts persist — for example, a client who prefers not to work on a safety skill that you assess as critical — the resolution should involve transparent discussion with the client (at their communication level), input from the family or legal guardian, documentation of the competing considerations, and a decision that limits any override of client preference to the minimum scope necessary. These situations should be rare, and when they occur, the rationale for overriding the client's preference should be compelling and well-documented.
In school settings, client participation often centers on IEP processes. Students can be prepared to participate in IEP meetings through rehearsal, visual supports, and pre-meeting conversations about their goals and preferences. The behavior analyst can also embed ongoing choice-making and self-advocacy opportunities into the school day. In residential settings, client participation extends to daily living decisions — choice of activities, routines, meals, and social interactions. The institutional structure of many residential settings can constrain participation, so the behavior analyst may need to advocate for systems changes. In adult day habilitation, participation involves incorporating individual goals and preferences into group programming. Across all settings, the common thread is that participation must be adapted to the setting's constraints while pushing those constraints toward greater client autonomy.
Client satisfaction tools should match the individual's communication and cognitive level. For verbal clients, simple rating scales (thumbs up/thumbs down, smiley face scales, Likert-type scales with visual anchors) can be used to assess satisfaction with specific goals, activities, and interactions. Structured interviews with concrete, simple questions provide richer information. For individuals with limited communication, observational measures of engagement and affect during different activities serve as proxies for satisfaction. Approach and avoidance behavior toward specific activities, therapists, or settings provides behavioral indicators of preference. Changes in challenging behavior that correlate with specific programming changes may also indicate dissatisfaction. Regular preference reassessment ensures that the reinforcers and activities used in programming continue to be valued by the client.
Institutional barriers — rigid schedules, staff ratios, regulatory requirements, organizational culture — are often the most significant obstacles to client participation. Addressing these barriers requires advocacy at the systems level. Start by identifying specific, concrete changes that would create space for participation without requiring massive organizational restructuring. For example, adding a choice point to a daily schedule, including a client input section on a treatment plan template, or allocating five minutes at the start of a team meeting for the client's voice. Present the case for these changes using data and evidence — cite the Ethics Code requirements, the research on outcomes associated with client participation, and the regulatory expectations of funding agencies. Build allies among staff and administrators who share the commitment to client autonomy. Start small, demonstrate results, and expand gradually. Systemic change takes time, but consistent advocacy supported by positive outcomes can shift institutional culture.
Families are essential partners in supporting client participation, but their role should complement rather than replace the client's own voice. Family members often have deep knowledge of the client's preferences, communication patterns, and values that can inform the participation process. They can also reinforce participation skills at home — encouraging choice-making, honoring expressed preferences, and modeling self-advocacy. However, the behavior analyst should be attentive to situations where family preferences diverge from client preferences. A family may prioritize goals that the client does not value, or may inadvertently speak for the client rather than creating space for the client's own voice. The behavior analyst's role is to facilitate a process in which both the family's input and the client's input are heard and integrated, with the client's own preferences given appropriate weight.
Assent and participation are related but distinct constructs. Assent refers to the client's ongoing indication of willingness to engage in treatment — the absence of behavioral indicators of distress, escape, or protest that would suggest the client does not want to continue. Assent monitoring is a minimum ethical standard that applies throughout all treatment activities. Participation goes beyond willingness to engage — it involves active involvement in shaping the treatment itself. A client who assents to a program designed entirely by the behavior analyst is tolerating the treatment. A client who has participated in selecting the goals, choosing the activities, and evaluating the outcomes is actively engaged in their own care. Both are important, but participation represents a higher standard of client involvement that behavior analysts should actively pursue.
Yes. Research consistently demonstrates that interventions developed with stakeholder input — including the input of the individual receiving services — produce better outcomes than interventions designed without such input. The mechanisms are straightforward: client participation increases the social validity of treatment goals, ensuring that the skills targeted are actually meaningful in the client's life. It increases motivation and engagement because the client is working toward goals they value. It reduces challenging behavior that may be maintained by the aversiveness of non-preferred activities or the absence of meaningful choice. Additionally, client participation provides the behavior analyst with information that improves clinical decision-making. A client who can indicate which activities they find rewarding, which social interactions they value, and which aspects of their routine they want to change provides assessment data that no standardized tool can replicate.
Documentation of client participation should be specific and embedded throughout the treatment plan. Rather than a generic statement that 'the client was consulted,' document the specific methods used to solicit client input (preference assessment results, structured interview responses, choice-making data), the specific client preferences identified, how those preferences were incorporated into goals and programming, and any areas where client preferences could not be accommodated along with the rationale. Ongoing documentation should include regular preference reassessment results, satisfaction assessment data, and any changes to programming made in response to client feedback. This documentation serves multiple purposes: it demonstrates compliance with Ethics Code requirements, it provides a record of the client's evolving preferences and priorities, and it creates accountability for the behavior analyst to genuinely incorporate client input rather than merely going through the motions.
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All behavior-analytic intervention is individualized. The information on this page is for educational purposes and does not constitute clinical advice. Treatment decisions should be informed by the best available published research, individualized assessment, and obtained with the informed consent of the client or their legal guardian. Behavior analysts are responsible for practicing within the boundaries of their competence and adhering to the BACB Ethics Code for Behavior Analysts.