Supporting Clinicians in Promoting Patient Assent: Balancing Treatment Goals with Dignity and Self-Advocacy

Overview & Clinical Significance

Patient assent has emerged as one of the most important ethical and clinical topics in contemporary ABA practice. With the inclusion of assent-related provisions in the 2022 Ethics Code for Behavior Analysts, the field has formally recognized that attending to clients' willingness to participate in treatment is not optional but obligatory. This course, presented by Karen Nohelty, provides practical guidance for BCBAs on how to gain patient assent, honor patient dissent, and balance these considerations with the pursuit of meaningful treatment goals.

The clinical significance of promoting patient assent extends across every dimension of service delivery. When patients assent to treatment, they are more likely to engage actively in therapeutic activities, form positive relationships with clinicians, demonstrate better learning outcomes, and generalize skills to natural environments. When assent is absent, even technically sound interventions may produce compliance without genuine learning, or they may produce avoidance and emotional distress that undermine the therapeutic relationship.

Karen Nohelty addresses a critical practical challenge: how to promote assent for patients with a range of severity and support needs. All patients are capable of communicating assent and dissent, but the forms of that communication vary widely. A verbal adolescent may say no or I do not want to. A minimally verbal child may push materials away, turn their body, cry, or attempt to leave. A patient with significant intellectual disability may become still, avert their gaze, or display changes in affect. Recognizing these varied forms of communication and responding appropriately is a clinical skill that many practitioners have not been explicitly trained in.

The course also addresses the tension between honoring dissent and pursuing treatment goals. There are situations in which a patient's dissent reflects a genuine preference that should be respected, and situations in which dissent may reflect temporary discomfort with a task that is ultimately in the patient's best interest. Navigating this distinction requires clinical judgment, ethical reasoning, and a structured decision-making framework. Karen Nohelty provides strategies for conducting risk-benefit analyses to determine how to respond to patient dissent in different clinical scenarios, making this course immediately applicable to everyday practice.

Background & Context

The concept of assent in behavior analysis has evolved significantly over the past decade. While informed consent from legal guardians has long been a standard practice requirement, the recognition that the patients themselves, many of whom are minors or individuals with intellectual disabilities who cannot provide legal consent, have a right to express their willingness to participate is a more recent development.

The 2022 Ethics Code for Behavior Analysts explicitly addresses assent, requiring behavior analysts to be attentive to the assent and dissent of clients. This codification reflects a broader shift in the field toward recognizing the dignity, autonomy, and communicative rights of the individuals who receive ABA services. It also reflects the influence of the neurodiversity movement and disability rights advocates who have called attention to the ways in which ABA services can, when poorly implemented, override the preferences and agency of the people they are designed to help.

The background for this course includes the practical reality that most BCBAs receive limited formal training in assent-based practice. Graduate programs cover informed consent as a legal and ethical requirement but may not provide detailed instruction on how to identify and respond to assent and dissent behaviors in clinical sessions. Supervisors may model assent-based practices, or they may model compliance-oriented practices that prioritize task completion over patient willingness. The result is wide variability in how assent is addressed across providers, clinicians, and sessions.

Karen Nohelty's course fills this training gap by providing concrete strategies that clinicians can implement immediately. The course acknowledges that assent is not a binary state, present or absent, but a dynamic process that fluctuates within and across sessions. A patient may assent to one activity and dissent from another. They may assent at the beginning of a session and withdraw assent as fatigue or frustration accumulates. They may dissent initially but come to assent after modifications are made to the task or the environment. Clinicians need the observational skills to detect these shifts and the clinical repertoire to respond flexibly.

The course also situates assent within the broader context of patient self-advocacy. Teaching patients to communicate their preferences, make choices, and express disagreement is not just an ethical obligation; it is a treatment goal with lifelong implications. Patients who learn to advocate for themselves in the therapy context are developing a repertoire that will serve them in educational, vocational, social, and healthcare settings throughout their lives.

Clinical Implications

The clinical implications of promoting patient assent are pervasive, affecting assessment, goal selection, session structure, intervention design, and the therapeutic relationship.

In assessment, promoting assent means including the patient's preferences and willingness in the assessment process. Before implementing a formal assessment protocol, the clinician should establish rapport, explain the activities in developmentally appropriate terms, and observe the patient's response. If the patient shows signs of distress or unwillingness, the clinician should modify the approach, offer breaks, or postpone the assessment rather than pushing through. Assessment data obtained from a distressed and unwilling patient are likely to underestimate the patient's true abilities and produce misleading results.

In goal selection, promoting assent means involving the patient in determining what they will work on. For patients who can express preferences verbally, this may involve direct conversation about treatment priorities. For patients with limited communication, it may involve observing which activities they engage in voluntarily, what materials they choose when given options, and what contexts produce the most positive affect. Goals that align with the patient's interests and motivations are more likely to produce engagement, learning, and generalization.

In session structure, promoting assent means building in choices, transitions, and breaks that give the patient control over the pace and content of their therapy. This does not mean abandoning structure or letting the patient dictate the entire session, but it does mean creating conditions where the patient has meaningful opportunities to influence what happens. The ratio of clinician-directed to patient-directed activities should be calibrated to the patient's tolerance and preferences, and should shift over time as the therapeutic relationship develops.

In intervention design, promoting assent means selecting procedures that the patient can participate in willingly. When a procedure consistently produces signs of distress or avoidance, the clinician should consider whether an alternative approach could achieve the same treatment goal with less aversiveness. This consideration is not about avoiding all discomfort; learning new skills often involves some degree of effort and frustration. It is about distinguishing between the productive challenge of learning something new and the unproductive distress of having one's preferences systematically overridden.

In the therapeutic relationship, promoting assent builds trust. When patients learn that their clinician will listen to their communication, respond to their preferences, and adjust activities based on their feedback, they develop a relationship characterized by safety and mutual respect. This relationship is not just ethically desirable; it is clinically functional. Trust facilitates cooperation, reduces problem behavior, and creates the conditions for learning.

Ethical Considerations

The ethical considerations surrounding patient assent are directly addressed by the 2022 BACB Ethics Code and represent some of the most nuanced ethical territory behavior analysts navigate.

Code 2.11 (Obtaining Informed Consent) specifies that behavior analysts must obtain the informed consent of the client or their surrogate and attend to the assent of the client. The distinction between consent and assent is important. Consent is a legal act performed by someone with the authority to make decisions on behalf of the client, typically a parent or legal guardian. Assent is the behavioral expression of willingness by the client themselves. Both are required, and they address different aspects of the client's rights.

Karen Nohelty's course provides particular guidance on responding to patient dissent, which is the area where ethical complexity is greatest. When a patient dissents from a treatment activity, the clinician must make a judgment about how to respond. Several factors inform this judgment. Is the activity clinically necessary? Could harm result from not completing it? Is the dissent related to a temporary state such as fatigue or hunger that could be addressed? Is the dissent persistent and consistent, suggesting a genuine preference? Has the patient been given enough information and experience to make an informed choice about the activity?

Code 2.15 (Minimizing Risk of Behavior-Change Procedures) supports the principle that clinicians should select the least restrictive effective procedures. When a patient dissents from a specific procedure but the treatment goal remains important, the clinician should explore alternative procedures that may achieve the same goal while being more acceptable to the patient. This exploration is not a failure of clinical resolve; it is an exercise of clinical creativity in service of both effectiveness and dignity.

Code 1.07 (Cultural Responsiveness and Diversity) intersects with assent in important ways. Different cultural contexts may have different expectations about the role of children and individuals with disabilities in decision-making. Some families may expect that the clinician will direct all aspects of treatment without consulting the patient. In these situations, the behavior analyst has an ethical obligation to educate families about the importance of assent while being respectful of cultural values. This requires skill in navigating conversations that may involve different perspectives on autonomy and authority.

The risk-benefit analysis framework that Karen Nohelty introduces is particularly valuable for ethical decision-making around assent. When a patient dissents from a treatment activity, the clinician should weigh the potential benefits of continuing the activity against the potential costs of overriding the patient's expressed preference. This analysis should consider both immediate and long-term consequences: the immediate benefit of completing a treatment trial versus the long-term cost of eroding the patient's trust, self-advocacy skills, and willingness to participate in future sessions.

Assessment & Decision-Making

Assessing patient assent requires systematic observation of behavioral indicators that vary across individuals. Karen Nohelty's course equips clinicians with strategies for identifying assent and dissent behaviors and making clinical decisions based on those observations.

The first step is to define what assent and dissent look like for each individual patient. For some patients, assent may be indicated by approaching materials, making eye contact with the clinician, smiling, or saying yes or okay. Dissent may be indicated by pushing materials away, turning away, saying no, crying, engaging in self-injurious behavior, or attempting to leave the area. For patients with more subtle communication repertoires, assent and dissent may be indicated by changes in muscle tension, vocalization patterns, or engagement level. Clinicians should work with the treatment team and the patient's family to develop individualized operational definitions of assent and dissent behaviors.

The second step is to establish a protocol for monitoring assent throughout each session. Assent is not something to be checked once at the beginning of a session and then assumed for the duration. Clinicians should continuously observe the patient's behavioral indicators and be prepared to pause, modify, or redirect activities when signs of dissent appear. Some clinical teams use structured assent checklists that prompt the clinician to assess the patient's willingness at regular intervals during the session.

The third step involves the risk-benefit analysis for responding to dissent. Karen Nohelty describes how to apply this framework. When a patient dissents, the clinician considers: What is the clinical importance of the current activity? What is the likely consequence of pausing or discontinuing it? What alternatives are available that might achieve the same goal? What is the patient communicating through their dissent? Is there an unmet need that could be addressed? What are the long-term implications of overriding the patient's expressed preference versus honoring it?

The fourth step is documentation. Clinicians should document observations of assent and dissent, the decisions they made in response, and the rationale for those decisions. This documentation serves multiple purposes: it creates a record of the clinician's ethical reasoning, it provides data for identifying patterns in the patient's responses, and it supports communication with the treatment team and the patient's family about how assent is being addressed.

The fifth step is teaching assent and dissent skills. For patients who do not yet have reliable ways to communicate their preferences, teaching these skills should be a treatment priority. Functional communication training can be adapted to teach the patient to express I want to continue, I want to stop, I want something different, or I need a break. These communication skills are among the most socially significant outcomes ABA can produce.

What This Means for Your Practice

Karen Nohelty's course provides a practical roadmap for integrating assent into your daily clinical practice. The strategies are not theoretical ideals for a perfect future; they are concrete steps you can take in your next session.

Begin by defining assent and dissent behaviors for each patient on your caseload. Work with your team and the patient's family to identify the behavioral indicators that suggest the patient is willing to participate and the indicators that suggest they are not. Add these definitions to the treatment plan so that all team members share a common understanding.

Next, establish assent-monitoring procedures for your sessions. Decide how you will check for assent, how often, and what you will do when you observe signs of dissent. Practice these procedures until they become a natural part of your session routine rather than an additional task that feels cumbersome.

Then, develop your risk-benefit analysis skills. When a patient dissents, practice walking through the framework: clinical importance, consequences of pausing, available alternatives, the patient's communication, and long-term implications. With practice, this analysis becomes faster and more intuitive while remaining rigorous.

Finally, prioritize teaching your patients to communicate their preferences. Every patient deserves the ability to say yes or no and to have that communication honored. This is not just an ethical obligation; it is one of the most meaningful skills you can teach.