Facilitating Treatment Adherence:
Training & Advocacy Tips
Norm Dahl, Ph.D., BCBA
Mount Olivet Rolling Acres’
Metro Crisis Coordination Program
612/869-6811
NormD@MetroCrisis.Org
Ineffective behavioral supports
increases persons’ risks of:
 Failing to make and maintain important
relationships.
 Failing to learn new adaptive skills.
 Being over-medicated.
 Being hurt due to preventable causes.
 Injuring others.
 Having “911” called on them.
 Separations from residential and/or
vocational programs.
Likely culprits contributing to
ineffective behavioral support
 Assessment fails to ID the function and
situations that set the occasion for CBs.
 Interventions are not matched to the
function and/or they do not target
suitable replacement behaviors.
 Interventionists are inadequately trained.
 Interventionists receive inadequate
follow-up support.
Of those culprits, the prime
suspects are…
 Inadequate training of interventionists.
 Inadequate follow-up support.
Common training practices
Med. Administration
 4-hour classroom training.
BSP Implementation
 Review Tx recs at IDT mtgs.
 Clearly defined expectations.  DSPs are rarely present.
 In-class knowledge checks.
 Instructors demo proper med
passing protocol.
 Knowledge is assessed via
written post-test.
 Analogue performance
assessment.
 In-situ performance
assessment.
 Protocol for noting &
addressing errors.
 A supervisor, who is not
properly trained to implement
the protocol, is expected to
train subordinates.
 Knowledge is not assessed
via a written post-test.
 Performance assessments,
analogue or otherwise, are
rarely carried out.
 Procedures for assessing and
addressing implementation
errors are rarely in place.
The problem is not with the DSPs
 Our first job must be to ensure DSPs
possess the knowledge and skills
needed to implement support plans.
 Our next job is to make sure they
use their knowledge and skills.
 In short, people must: (a) know what to
do, (b) know how to do it, and then (c)
choose (or are motivated) to do it.
Training & Follow-up are key
 Good training can provide people with
the knowledge and skills they need to
properly implement behaviors plans.
 Good
training is a first-line risk mgmt. tool.
 Practice helps people refine their skills.
 Follow-up, in the form of monitoring
with immediate feedback, improves
knowledge and proper use of skills.
Keys to effective treatment
(oops, I mean keys to effective training)
1) The clinician starts by defining
knowledge and performance
standards.
2) The clinician trains all who are
expected to implement the plan.
3) At the training, the clinician provides a
succinct written account of the: (a)
rationale, (b) intended outcome, and
(c) what interventionists need to do
(i.e., the performance standards).
Effective Training (continued)
3) The clinician reviews the document &
describes each component of the plan
(i.e., the rationale, goals, procedures).
~ I like to include a treatment integrity check
list or a treatment monitoring tool along
with the written plan (more in this later).
4) The clinician demonstrates how to
implement the procedures in the plan.
~ I like to use the monitoring tool as a cheat
sheet to ensure I don’t miss anything and
encourage trainees to do the same.
Effective Training (continued)
5) The clinician demonstrates how to use
the monitoring tool and provides
feedback to interventionists.
6) Everyone takes turns playing the role of
the consumer, the interventionist, and
the monitor/feedback provider.
7) The clinician describes how monitoring
is as much a part of the plan as the
implementation protocol.
Agenda from a recent DSP training
 Review training document & monitoring
checklist (demonstrate how to do/use both).
 Role-play/practice implementing the
protocol.
 Role play/practice using the monitoring
checklist.
 Role play/practice providing feedback.
 Discuss the importance of consistency.
 Reach consensus on an implementation
and monitoring schedule.
Why Monitor Implementation?

It sends the message that proper
implementation is important & expected.

It’s the only way to know if treatments
are being implemented as planned.

It provides a forum for praising
desirable implementation and
correcting improper implementation.

It allows you to assess the client’s
responsiveness to the plan.
Keys to effective monitoring
 Identify the person(s) responsible for
monitoring.
 Make sure everyone knows what the
monitoring plan entails.
 Use a monitoring tool to reduce
subjectivity & minimize observer drift.
 Monitor all interventionists.
Effective Monitoring (continued)





Monitor when CBs are most likely.
Monitor frequently at the outset.
The more significant the risks posed
by persons’ CBs, the more frequently
their plans should be monitored.
Make sure people know they are being
monitored (and what’s being monitored).
And finally, monitor a monitor’s
monitoring from time to time.
Treatment Integrity/Monitoring Checklist (Example I)
Equipment is available and in proper working order:
_____
_____
Door & window alarms; (similar to a fire drill, periodically set off alarms to see if they
are working.
_____
Cell phone. (is it available, is it charged?)
_____
Locks on doors work properly?
Direct Observation:
_____
Alarms are armed when ___ is on site?
_____
Doors are locked when ___ is on site?
_____
___’s shoes are locked up?
_____
Staff are running the levels program and following his schedule?
_____
Staff immediately prompt ___ to return to living room should he stand at the doorway?
_____
If ___ did not comply within 3-s, staff escorted him to the living room?
Regarding outings:
_____
Before opening the door to the house (or a vehicle) staff remind that he needs to walk directly to
the designated location
_____
Practice (spot check on random basis or review at weekly staff meetings):
_____
Staff can paraphrase the 911 script?
_____
Staff can paraphrase the PRN protocol?
_____
Staff can identify and describe Level I (precursor) behaviors?
_____
Staff can describe and/or demonstrate at least 3 of the protocol included under Level I?
_____
Staff can describe and/or demonstrate at least 3 of the daily interaction protocols?
Data (spot check on a random basis)
_____
Collected consistently?
_____
Collected accurately?
_____
Person who assesses data collection practices should provide feedback to staff.
_____
Review data during weekly house meetings.
Treatment Integrity/Monitoring Checklist (Example II)
Date_______ Staff Observed ______ Staff Observing______
Task 1
Task 2
Task 3
1 Presented card options…… ______
______
______
2 Gave 15-s to choose……… ______
______
______
3 Presented card up to 3 x….. ______
______
______
4 Chose for him if necessary.. ______
______
______
5 Allows for an alternative.… ______
______ ______
6 Gave 3+ w/in task choices.. ______
______
______
7 Gave 15-s between choices. ______
______
______
8 If needed, gave help to
complete 1st step of task….. ______
______ ______
9 Ignored CB if it occurred… ______
______
______
10Praised choosing/task comp ______
______
______
11Gave token upon task comp ______
______
______
Treatment Integrity/Monitoring Checklist (Example III)
Why Provide Feedback?
 You greatly increase the probability that
the plan will be implemented as
intended.
 You greatly increase the probability that
the plan will produce the desired effects.
Keys to Effective Feedback
 Feedback should be immediate.
 Periodically
throughout, if it won’t
interrupt the flow of implementation,
 Or, in a summative fashion at the end
of implementation.
 Only positive feedback from seniorlevel supervisors should be delayed.
 Feedback should be private
 Positive & corrective should both be
provided in private.
Effective Feedback (continued)
 Feedback should be sincere.
 Feedback should be based on a specific
set of standards to which DSPs have
been sufficiently trained.
 Feedback should be behavior-specific.
Effective Feedback (continued)
 Start feedback sessions by focusing on
something the person did right.
 Corrective feedback should inform
people of what they “should do” not
what they “shouldn’t do.”
 End the session by reiterating what a
person did right or by commiserating
about how it takes practice and a lot of
concentration to develop new skills.
Additional things you can do as a
clinician or trainer
 Pitch Tx recs. as being consistent with
beliefs held by stakeholders.
 Address behaviors important to DSPs.
 Include at least 1 rec. they will have little
difficulty doing.
 Provide a self-monitoring tool.
 Build in choice opportunities for DSP.
 Establish reasonable expectations for
change.
As an Advocate…
 Share your belief in the plan with staff.
 Invite mgmt. personnel to attend team
meetings and share an expectation that
the plan will be implemented as written.
 Don’t allow changes in a plan until you
assess if the plan was implemented with
integrity.
As an Advocate (continued)
 Include proper implementation of the
BSP as an item in persons’ RMA&Ps.
 Include monitoring on RMA&Ps as well.
 Make sure BSP training is included in
the “special training” section of ISPs.
 Ask that certain implementation
responses be documented on persons’
medication administration records.
As an Advocate (continued)
 Request data on DSPs’ implementation
behaviors in addition to behavioral data.
 Ask for a plan that specifies how
implementation will be assessed and
how errors will be addressed.
 If non-adherence is an issue, find out
why.
 Insufficient
training or follow up?
 Competing responsibilities?
As an Advocate (continued)
 Higher up in the County
 Include
Tx adherence as a performance
standard in contracts.
 Before offering additional funding for
staffing, make sure there is a specific
plan for how the time will be used.
 Request data that allow you to assess if
(and how) the additional service you are
purchasing is being provided.
 If you fund 1:1 staffing, you should
expect continuous therapeutic
engagement.
Take Home Message
 Minimize undesirable outcomes (risks) by
taking BSP implementation as seriously
as you take proper med. administration.
 Increase adherence by ensuring people
get a chance to practice implementing
the plan during initial training.
 Increase adherence with monitoring.
 Increase adherence by offering F-Back.
 Advocate for monitoring as an integral
component of behavior support plans.
And one more thing you can do
 Make a referral to MCCP for refresher
training and the development of a
treatment adherence protocol.
 Typically, because these referrals will
not include an assessment or treatment
recommendations, only 60-80 “units” of
service will be needed.

Approximately ½ the time of a typical referral.
 Call MCCP @ 612/869-6811.