by Sorah Stein, PhD, BCBA-D, CSE, CSES and Christine Barthold | PhD, BCBA-D, LBA, NBC-HWC, ACE-CPT
Jeff is a burnt-out BCBA, looking for a new challenge. He has always been an avid bodybuilder and “eats clean.” Two people at his gym are looking for a trainer. One is a 35-year-old who gave birth two months ago, is breastfeeding, and is looking to shed 50 pounds of baby weight. He puts her on a strict Paleo diet and trains with her 5-6 days a week, focusing on high-intensity cardio and ab exercises. The other is a 55-year- old with osteoarthritis, coronary heart disease, and diabetes. He has this client working out 4 days a week using High Intensity Interval Training (HIIT) as well as target heart rate training and suggests that they might have the best results with intermittent fasting. He uses reinforcers like verbal praise and gift cards for every 5 pounds lost, takes data on their progress, and shows them their graphs each week. They are both pleased with their progress.
If you haven’t had a baby, aren’t a trainer, or are not trained in health and wellness, this vignette probably seems great. Switch careers, beat burnout, and make a difference, right? Unfortunately, Jeff is putting his clients at risk. A client that closely post-partum most likely has diastasis recti. Her abdominal muscles parted to make way for the baby and emphasis on abs might cause injury. If not carefully monitored, the diet may result in malnutrition for the baby, and this mother needs additional calories to feed her child. Hydration is key when working out, and it doesn’t look like Jeff has taken that into consideration. The second client may be cleared for HIIT training but needs to be closely monitored for signs of distress. They could take medications that artificially reduce heart rate, which would make target heart rate training frustrating and ineffective. Intermittent fasting may cause issues with blood sugar if not closely monitored by a physician.
In short – Jeff might be having the time of his life, but he’s putting his clients at risk for injury or even death with his practices.
Let’s look at another scenario.
A BCBA is called by a residential provider in another state. They have a resident who is lying on the kitchen floor and repeatedly pressing his pelvis into the floor in a thrusting manner. The provider wants help teaching the resident to masturbate effectively, and in his bedroom. The BCBA provides them a task analysis for masturbation and tells the residential staff to tape it to the resident’s wall as a stimulus prompt to help him learn that he should only masturbate in his bedroom.
If you don’t know a lot about sexual health and anatomy, this might look like an appropriate intervention. However, if you’ve ever tried to achieve sexual pleasure in that manner, you’d quickly find it’s not quite enjoyable. That said, putting lower abdominal pressure on a hard surface, such as a kitchen floor, can alleviate abdominal pain. In this case, the BCBA referred the residential provider to a physician, who determined that the resident had a significant bowel impaction and treated it successfully.
There is a recent uptick in Board Certified Behavior Analysts stating interest and purporting expertise in areas such as sex education, coaching, and athletic performance. This is concerning for many reasons.
Some suggest that sexual behavior is just topographies of behavior, and as such, it falls under the purview of BCBAs (Stein, 2022). Looking at the BACB task list, nothing about sexuality is listed, just like nothing about feeding is listed — and people seek consultation or acquire additional training and certification in that. Those with formal training in sexuality learned that sexual behavior is complex and involved interactions between hormones, physiology, social and cognitive skills (WHO, 2010), the environment, and reinforcement history. Those without this training might easily overlook essential elements.
Similarly, habit change should be the domain of behavior analysts, right? At present, as it was not too long ago for BCBAs, anyone can call themselves a coach independent of training, certification, or expertise. While that makes it easy for BCBAs to become coaches, it also brings with it the risk of promoting snake oil interventions. It can also result in BCBAs practicing out of scope and causing harm.
There are a number of reputable exercise certifications. Examples include the American Council on Exercise and the American College of Sports Medicine. There are two accepted certification tracks for those interested in a coaching career. The International Coach Federation (ICF) is the older of the two and has multiple levels of coach credentials. Each level requires coursework, practical experience, and a certification exam. Coaches are not limited in their scope while some have specialized training to work with individuals with ADHD or executives. Similarly, the National Board of Health and Wellness Coaching provides a credential more aligned with the trajectory of the BACB.
Trainers, health coaches, and the like run the risk of doing great harm if not properly trained in anatomy, physiology, and typical chronic health conditions. Take, for example, a client who comes to the trainer or coach for an exercise plan. The client has heart disease and diabetes. If the trainer/coach is not properly educated on how these two diseases can affect exercise, they run the risk of recommending practices that might result in injury or even death.
Coaches and trainers who are certified by reputable organizations are less likely to recommend dubious practices. They are also specifically trained in issues related to aging, sexism, racism, and ableism. Weight bias is of particular concern to the trainer and the health coach.
Expertise in any domain requires extensive training — both education and practice with mentorship or feedback (Brodhead, et al., 2018; Leblanc, et al., 2012). Many of the people asserting their expertise lack formal training in sexuality or coaching. Others lack formal mentorship with established professionals. Consider the supervision requirements for BCBAs — certified for 5 years, 8 hours of training on supervision, and 3 hours per certification cycle on supervision.
Did your local ABA sexuality professional have mentorship in sexuality from someone meeting similar requirements? Does your local ABA sexuality professional know about interactions between hormones and medication or how hormonal changes throughout the lifespan can affect behavior? Is your local ABA sexuality professional well-versed in the literature on sexual abuse prevention or are they using compliance training in their clinical work, which directly opposes any self-advocacy and abuse/exploitation skills (Wood, 2018)?
Likewise, is your BCBA-trainer/coach trained on appropriate movements and cueing? Are they apprised of the latest evidence regarding movement patterns? Do they know the effects of exercise on aging, mobility, and managing chronic disease? Do they also know how aging, mobility, size, and chronic disease can affect safe exercise? Is your BCBA trained in healthy eating guidelines? Or do they espouse fad diets or a specific way of eating? Are they overly focused on weight loss over quality of life?
Given that most BCBAs do not have this level of training, what is an ethical BCBA to do? For starters, get a good, certified personal trainer or health coach, or get certified as one before coaching others. In the realm of sexual behavior concerns, first, check for possible medication effects or interactions (Silverberg, 2006; Stein & Dillenburger, 2017). Second, when conducting any functional assessment, only use indirect methods; evoking sexual behavior, even under assessment conditions is ethically problematic (Stein & Dillenburger, 2017). Third, reach out to an ABA professional with formal training or credentials from a recognized certifying organization.
Brodhead, M. T., Quigley, S. P., & Wilczynski, S. M. (2018). A call for discussion
about scope of competence in behavior analysis. Behavior analysis in practice, 11(4), 424-435.
LeBlanc, L. A., Heinicke, M. R., & Baker, J. C. (2012). Expanding the consumer base for
behavior-analytic services: Meeting the needs of consumers in the 21st century. Behavior Analysis in Practice, 5(1), 4-14.
Silverberg, C. (January 22, 2006). How to manage sexual side effects of prescription
medications. http://sexuality.about.com/od/sexualsideeffects/ht/managesideeffec.htm
Stein, S. (2022). Sexuality and People with Intellectual and Developmental Disabilities.
Stein, S., & Dillenburger, K. (2017). Ethics in sexual behavior assessment and support
for people with intellectual disability. International Journal on Disability and Human Development, 16(1), 11-17.
World Health Organization (WHO, 2006) Sexual and reproductive health: Gender and human rights. Retrieved from
http://www.who.int/reproductivehealth/topics/gender_rights/sexual_health/en/
Wood, S. (February 20, 2018). International Women’s Health Coalition. Retrieved from