By Matt Harrington, BCBA · Behaviorist Book Club · April 2026 · 12 min read

A Clinician's Guide to Compassionate and Ethical Decision-Making During Crisis Conditions

Overview & Clinical Significance

Crisis conditions expose the fault lines in our ethical frameworks. When the COVID-19 pandemic disrupted ABA service delivery worldwide, behavior analysts confronted questions that no training program had prepared them to answer. Should in-person services continue when doing so risks viral transmission? Should services transition to telehealth when the evidence base for remote ABA delivery was thin? Should clinicians follow blanket organizational policies, or should each case be evaluated individually based on the specific risks and needs of the client and their family?

The position statement by Cox, Plavnick, and Brodhead published during the early pandemic argued against a one-size-fits-all approach to service discontinuation. Their core contention was that blanket policies, whether mandating continuation or cessation of all services, failed to account for the enormous variability in client need, risk tolerance, and clinical context. An individual whose severe self-injury required hands-on intervention to prevent tissue damage faced a fundamentally different risk calculus than an individual working on social skills in a group setting.

This presentation, featuring Linda LeBlanc, Junie Lazo-Pearson, Joy Pollard, and Lorri Unumb, examined how compassion and ethics should interact in crisis decision-making. The inclusion of a legal perspective alongside clinical ones reflects the reality that crisis decisions in ABA do not occur in a purely clinical vacuum. Insurance mandates, state emergency orders, liability considerations, and regulatory guidance all constrain and inform clinical judgment.

The clinical significance of this topic extends well beyond the specific crisis of COVID-19. Natural disasters, facility closures, workforce shortages, personal emergencies affecting clinicians or families, and public health crises all create conditions where standard operating procedures break down and practitioners must make decisions under uncertainty. The ethical frameworks and decision-making processes developed during the pandemic provide templates for navigating any crisis that disrupts the normal conditions of service delivery.

Behavior analysts who developed crisis decision-making skills during the pandemic are better equipped to handle future disruptions. Those who defaulted to organizational directives without engaging in independent ethical analysis may find themselves similarly unprepared when the next crisis arrives. The lesson is not about any specific crisis but about building the ethical reasoning capacity to navigate disruptions that have not yet been imagined.

Background & Context

The COVID-19 pandemic created an unprecedented natural experiment in ABA service delivery. Within weeks, practitioners who had delivered services exclusively in person were asked to determine whether those services could be provided remotely, whether the risks of in-person delivery were justified, and how to maintain treatment integrity under conditions that bore no resemblance to the controlled environments described in the research literature.

The initial professional response was fragmented. Some organizations halted all services immediately, prioritizing infection control. Others continued all services unchanged, prioritizing treatment continuity. Neither extreme represented optimal ethical reasoning. The organizations that navigated the crisis most effectively were those that adopted individualized decision-making frameworks, evaluating each client's situation based on the severity of their clinical needs, the risks of service disruption, the feasibility of remote alternatives, and the health vulnerabilities of all parties involved.

The legal landscape during COVID-19 added layers of complexity. State emergency orders varied in their implications for healthcare services. Some states classified ABA as an essential service, permitting in-person delivery. Others did not, creating legal uncertainty for organizations that continued face-to-face treatment. Insurance companies issued emergency authorizations for telehealth that would not have been approved under normal circumstances. These regulatory shifts created opportunities and obligations that required practitioners to stay informed about a rapidly changing legal environment.

The telehealth transition exposed both possibilities and limitations. For some clients and families, telehealth-delivered ABA services proved surprisingly effective, particularly for parent training components, consultation, and higher-level skill maintenance. For others, particularly individuals requiring physical prompting, crisis management, or intensive behavioral intervention, the limitations of remote delivery were severe. The differential effectiveness of telehealth underscored the importance of individualized assessment rather than blanket policy.

Compassion entered the ethical calculus in ways that are not always foregrounded in professional ethics discussions. Families were experiencing extraordinary stress: job loss, health anxiety, social isolation, disrupted routines, and the loss of support systems. Clinicians were managing their own parallel stressors while being asked to maintain professional effectiveness. The intersection of personal vulnerability and professional obligation created conditions where compassion was not merely an ethical ideal but a practical necessity for sustaining the therapeutic relationship.

The historical context also revealed disparities. Families with greater resources, including reliable internet access, adequate space for therapy, flexible work arrangements, and lower health vulnerability, were better positioned to benefit from telehealth alternatives. Families already facing socioeconomic disadvantages experienced disproportionate service disruption, exacerbating existing inequities in access to ABA treatment.

Clinical Implications

The decision-making frameworks developed during the pandemic have lasting clinical implications that apply whenever standard service delivery is disrupted. The most important principle is individualized risk-benefit analysis for each client, explicitly weighing the risks of continuing services against the risks of discontinuing them.

For a client whose challenging behavior includes life-threatening self-injury, the risk of service discontinuation may include serious physical harm, emergency department visits, and potential hospitalization. These risks must be weighed against the infection risk of in-person service delivery, the feasibility of implementing safety protocols, and the availability of crisis management plans that can be executed by caregivers with remote support. The calculus for this client is fundamentally different from that of a client whose treatment targets social communication in community settings, where disruption is inconvenient but not dangerous.

Crisis conditions also require practitioners to reassess treatment priorities. Goals that were appropriate under normal conditions may need to be temporarily suspended in favor of maintenance targets, caregiver support, or crisis prevention. A BCBA who was working on academic readiness skills may need to shift focus to maintaining communication, managing challenging behavior that escalates under stress, and supporting caregivers in implementing basic behavioral strategies without professional support.

The caregiver's role expands dramatically during service disruptions, and the clinical implications of this expansion deserve careful consideration. Parents who were accustomed to having a trained technician implement behavioral procedures for twenty or thirty hours per week may suddenly be asked to serve as the primary interventionist. This shift requires rapid, context-sensitive training that prioritizes the most critical procedures and acknowledges that caregiver implementation fidelity will be lower than technician implementation. Setting realistic expectations and providing ongoing support through remote supervision protects both the caregiver's wellbeing and the client's treatment integrity.

Documentation during crisis conditions requires particular attention. Decisions to modify, reduce, or suspend services should be documented with the clinical rationale, the risk-benefit analysis conducted, the alternatives considered, and the plan for resuming standard services when conditions permit. This documentation protects the practitioner, informs future clinical teams, and satisfies the ethical obligation to maintain accurate records that reflect the actual basis for clinical decisions.

The transition back to standard services after a crisis presents its own clinical challenges. Skill regression during service disruption may be significant, and resuming the pre-crisis treatment plan without reassessment wastes time and frustrates families. A post-crisis reassessment that identifies current functioning levels and adjusts goals accordingly demonstrates clinical competence and respect for the client's actual needs rather than assumptions about where they should be.

Ethical Considerations

Crisis conditions test whether ethical commitments are genuine or performative. When conditions are stable and resources are adequate, maintaining ethical practice is relatively straightforward. When conditions are unstable and resources are scarce, the practitioner's true ethical commitments are revealed by the decisions they make under pressure.

The obligation to provide effective treatment (Code 2.01) does not disappear during a crisis, but it must be balanced against the obligation to do no harm. In-person ABA services during a pandemic carry infection risk for the client, the client's family, the clinician, and the clinician's family. Providing treatment that benefits the client's behavioral repertoire while exposing them and their family to a potentially deadly virus requires an honest assessment of whether the benefit justifies the risk. For some clients, the answer is clearly yes. For others, clearly no. For many, the answer depends on specific circumstances that require individualized analysis.

Informed consent takes on heightened importance during crisis conditions. Families must understand not only the standard risks and benefits of treatment but the specific risks introduced by the crisis, the modifications being made to standard procedures, and the limitations of those modifications. A family consenting to telehealth-delivered ABA should understand what the service can and cannot accomplish through this modality, what the expected differences in outcomes are compared to in-person delivery, and what criteria will trigger a recommendation to return to in-person services.

Equity and access represent ethical obligations that crisis conditions make more visible. When telehealth becomes the primary service delivery method, families without reliable internet, adequate devices, or sufficient physical space are effectively excluded. The ethical response is not simply to note the disparity but to actively seek solutions, whether through device lending programs, alternative communication methods, or hybrid service models that maintain some in-person contact for families who cannot access telehealth effectively.

Practitioner self-care during crisis conditions is an ethical issue, not merely a personal one. A behavior analyst operating under extreme personal stress, whether from health anxiety, caregiving responsibilities, financial pressure, or social isolation, is at increased risk of impaired professional judgment. Recognizing this risk and taking steps to mitigate it, including seeking supervision, reducing caseload if possible, and accessing personal mental health support, protects clients by ensuring that the practitioner is functioning at a level consistent with competent practice.

Organizational decisions during crises carry ethical weight that extends beyond individual practitioner conduct. Organizations that pressured clinicians to continue in-person services without adequate safety protocols placed both staff and clients at risk. Organizations that suspended all services without providing alternative support abandoned families during their period of greatest need. Ethical organizational leadership during a crisis requires transparent communication, individualized decision-making, resource allocation that prioritizes the most vulnerable, and willingness to absorb financial losses rather than compromise safety.

Assessment & Decision-Making

A crisis decision-making framework for ABA service delivery should include structured assessment of client risk, service modification feasibility, caregiver capacity, and ongoing monitoring. This framework can be activated whenever standard service delivery is disrupted, regardless of the specific nature of the crisis.

Client risk assessment begins with evaluating the consequences of service disruption. For each client, identify the specific risks associated with reduced or discontinued services. These may include skill regression, escalation of challenging behavior, loss of communication gains, caregiver burnout, and the potential for emergency situations such as severe self-injury or elopement. Rate the severity and likelihood of each risk. Clients at highest risk should receive priority for continued or modified services.

Service modification feasibility examines which components of the current treatment plan can be delivered through alternative methods. Parent training, consultation, data review, and some forms of naturalistic teaching may transfer well to telehealth. Physical prompting, crisis management, and community-based instruction typically cannot. For each client, map current treatment components onto available delivery methods and identify which can be maintained, which must be modified, and which must be temporarily suspended.

Caregiver capacity assessment evaluates the family's ability to participate in modified service delivery. Factors include the caregiver's availability (work schedule, other children, health status), their existing skill level with behavioral procedures, their access to technology for telehealth, their physical space for implementing therapy activities, and their current stress level. A caregiver who is managing their own health crisis, working from home, and supervising multiple children's remote schooling has fundamentally different capacity than a caregiver with flexible time and a supportive household.

Ongoing monitoring during crisis conditions should occur more frequently than during standard service delivery, not less. Weekly check-ins with families, even brief ones, allow the practitioner to detect emerging problems, adjust the modified treatment plan, provide emotional support, and maintain the therapeutic relationship. Monitoring should assess both treatment outcomes and caregiver wellbeing, recognizing that the two are interdependent.

Decision documentation during a crisis serves multiple functions. It provides the clinical rationale for modifications, protects the practitioner and organization in case of adverse outcomes, informs future crisis planning, and demonstrates to payers and regulators that decisions were made thoughtfully rather than arbitrarily. A decision log that records the date, client, risk assessment, modification made, rationale, and planned review date creates an organized record of crisis management decisions.

Post-crisis reassessment is the final critical step. When standard services resume, each client should receive a comprehensive reassessment rather than simply restarting the pre-crisis treatment plan. Identify current functioning levels, evaluate which crisis-period modifications should be retained because they proved effective, and develop updated goals that reflect the client's actual post-crisis presentation.

What This Means for Your Practice

Every practitioner will face service disruptions at some point. Having a decision-making framework ready before the crisis arrives is dramatically more effective than trying to build one under pressure. Take the crisis decision-making principles from this presentation and adapt them into a template that fits your practice context: a brief checklist for client risk assessment, a service modification planning tool, and a caregiver capacity screening questionnaire.

Review your current caseload through a crisis readiness lens. For each client, identify which treatment components are most critical and least substitutable, what the highest-risk consequences of service disruption would be, and what modified delivery options are feasible. This proactive assessment does not require immediate action but creates a resource you can activate rapidly when disruption occurs.

Advocate within your organization for crisis planning that goes beyond business continuity. Clinical crisis planning should address how treatment decisions will be individualized, how families will be communicated with, how staff safety and wellbeing will be protected, and how services will be reinstated after the crisis resolves. Organizations that invest in crisis planning before they need it respond more effectively, more ethically, and with less harm to clients and staff when disruption arrives.

Carry the compassion emphasis from this presentation into your standard practice. Crisis conditions magnified the importance of compassion, but the principle applies always: families receiving ABA services are navigating challenges that extend far beyond the treatment room, and practitioners who acknowledge this reality build stronger therapeutic relationships and more effective service delivery partnerships.