September 24, 2023 • 39 mins
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jonathan (00:29):
My guest today is Dr.
Ellie Kazemi.
Dr.
Kazemi merges behavioralscience, advanced technology and
database decision making withmany years of experience working
with leadership to promotestrong organizational cultures,
practical and efficienttraining, and transparent
messaging and communication.
She's a tenure track professorat CSUN, where she founded the
MS in Applied Behavior Analysisprogram in 2010, and teaches
(00:52):
undergraduate and graduatecoursework in organizational
management and behavioralanalysis.
She's also served as the chiefscience officer at the
Behavioral Health Center ofExcellence, BHCOE, an
accrediting organization whereshe oversaw standard
development, evaluationmethodology, measurement
science, and thought leadership.
Ellie, welcome to the pod.
Dr. Ellie Kazemi (01:12):
Thank you.
It's nice to be here.
Jonathan (01:14):
Alright, this is so topical.
We're recording this, not onlyon today.
April 27th is a day withouthate, but it's, um, almost
exactly one week after I got tosee you at the Autism Investor
Summit.
And I was sitting in the frontrow and just like grinning ear
to ear on all of the data youwere sharing, about burnout and
what makes people stay andretention and turnover and all
(01:35):
kinds of stuff.
And so, it's an honor to haveyou here, Ellie, and let's start
with what got you so interestedin learning more about provider
burnout and retention.
Dr. Ellie Kazemi (01:43):
Well, um, I've been interested in that for some
time.
I think when we put out theturnover paper, it was like
2010, we were beginning torealize that there is such a,
incredible amount of turnover inthat behavior technician level.
Um, and I think that, In anyprofession, what you're
interested in is why are peopleleaving?
because you want to do somethingabout that.
(02:04):
And you know the people that areleaving for good reasons.
You want to encourage'em on andbe happy about that and, get
them to a better place.
But if people are leavingbecause you're not doing
something right or you just needto change your messaging or you
need to change the culture ofwhat you're doing.
Those things I think are doableand good feedback for us as a
community.
(02:24):
So I've been interested in thistopic, at many different levels,
and I think more interesting isprobably post covid, how
everyone else has gained so muchinterest in the area.
So I feel like I've kind of beenwatching this rise in turnover
and likelihood to quit, but, Ithink that Covid sort of made us
(02:45):
all very aware that we have aproblem.
Jonathan (02:48):
Yeah.
Let's go deeper on that.
'cause one of the things Itotally didn't appreciate until
I saw it in your presentation,and there's a Harvard Business
Review article you highlighted,called The Great Resignation
Didn't start with Covid.
Tell me more.
Dr. Ellie Kazemi (03:03):
Yeah.
You know, I thought HarvardBusiness Review did such an
awesome job with this, wherethey showed that this
progressive graph showed veryclearly that what we're seeing
is a rise in, voluntary turnoverand silent quitting from
individuals, but that because ofjob insecurities or people
worrying about furloughs andwhatnot during Covid, there was
(03:25):
actually a period of time whenpeople were keeping their jobs,
so right afterwards weexperienced what we would've
typically experienced as thenext rise, but it just feels
like so much more.
And I think that that is exactlywhy I've been interested in,
turnover and burnout for sometime because we're seeing it and
we're seeing it progressively,but it's only human.
(03:47):
When something happens justslightly a little bit more every
time there's a shaping process,we don't feel it's happening.
Um, and so I think it's reallygiving us some time to think
about this, uh, which isimportant.
Jonathan (03:59):
Yeah, and it shows, I, I think just a fundamentally
different sort of nature ofcontract between employee and
employer than we've experiencedin the past.
And that we, we may or may not,right, as organizations or
specifically as ABA providershave tools that we're equipped
to address that.
But of the many things that wereso powerful about your
presentation is you shared someof the data with your
(04:20):
conversations with, I think itwas like, 250 RBT and BCBAs in
which you listened and you haddirect conversations with them
about what they love feeling andseeing in their jobs, what keeps
them coming to work, and alsowhat burns them out.
Tell me more about yourfindings.
Dr. Ellie Kazemi (04:37):
Yeah, I love that because I think what
happened for me was, wheneveryone started to recognize
this as an issue, and you know,our turnover paper had been
there.
People had looked at it before.
But then more than ever, I'mgetting notifications from
ResearchGate that people areactually looking that paper up
now, post Covid.
I really wanted to shift thefocus'cause it's important if we
(04:58):
see Covid as the cause or themajor explanation, if something
happened during Covid, we'relikely to look at different
things than what is itprogressively that we're doing
as corporations, asorganizations, as employers that
may potentially be resulting ina higher and higher level of
individuals leaving.
And I think it, that shiftingthat focus is really important,
(05:20):
uh, from my perspective.
so I put out a call and I'vebeen hearing from a lot of
individuals, that we'vegraduated over the years, we've
graduated over 400 BCBAs fromthe Cal State Northridge
program.
And I can't even say how manybehavior technicians'cause each
semester alone I teach 300students or so.
(05:40):
So we absolutely have our ownbase of individuals who were
contacting me, talking to meabout changing jobs, leaving the
profession as a whole, and Ididn't want the sample to just
be the individuals that we hadgraduated or that came to CSUN.
So I posted on social media,believe it or not, just, Hey, if
you wanna talk about, yourprofession, if this is not what
(06:02):
you envisioned.
gimme a call, text me or send mesomething.
And the number of individualswho wanted to speak just blew me
away.
They, reached out, they wouldsend me such personal
informations, they would writeout what felt like just these
events in their lives that theyhad sat down and thought about
(06:24):
the vulnerability was prettyincredible.
And the other part of what wasincredible was that I had not
said, you know, hey supervisors,I assumed who I was speaking to
was supervisors.
but actually I received callsand requests to speak from CEOs,
from, uh, academicians, frombehavior technicians.
(06:46):
So it was definitely across,positions where they wanted to
talk about what they thought theprofession would be, why they
came to it, what they loved andwhat was changing for them, or
why they were seeking somethingelse.
so I was able to synthesizeacross those stories and what
(07:06):
became very clear to me when youspeak to over 250 people, is the
similarities, the universaltruths come up.
Right?
so I think that that's beenvery, uh, very cool.
In my history, I've not donethat much qualitative research,
but I can definitely see thevalue in having spoken to
people, cause what I didn'twanna do, Jonathan, is to put
out a call and say, Hey, are youburned out?
(07:28):
Tell me more about your feelingsof burnout, because we know that
that's been done to teachereducation, and all it does is it
burns people out.
so I wanted folks to, to connectback to why they're here, and
tell me how we could get there.
Jonathan (07:45):
So I'm, I'm like on the edge of my seat.
You gotta share some of theuniversal truths that you were
hearing.
Uh, I remember in particular,like stories about a behavior
technician, for example, who waslike expected to go into this
really challenging situationwith a kiddo in bed and yeah.
Tell me more about the universaltruths.
Dr. Ellie Kazemi (08:03):
Yeah.
so, I don't think we have enoughtime for me to share with you
the personal stories at thoselevels.
I selected stories ofindividuals that I felt really
were echoed across thetechnician and the supervisor,
and then of course the CEOs.
Um, and I wanted thesimilarities to emerge and I
think for the most part it'svery clear that people came to
(08:28):
the clinical portion of ourfield from a desire to change
things, to be able to be aneffective agent of change, I
want to be able to helpfamilies.
many individuals shared thoseexact moments where they fell in
love and it was typically fellin love with a client or fell in
love with, um, like our CEOs,would talk more about these
(08:51):
moments of feeling like theycould make a difference in the
lives of their employees whenthey watch them blossom.
And so there were clearly thesemoments of, I want to help and
when I see that change, when Iget to access being effective,
that feels great.
Uh, and that was definitelyuniversal.
Um, the other was, Feelingappreciated.
(09:14):
Which was interesting becausethe technicians spoke about
appreciation more from theperspective of when the families
want me around, when they arethankful when their child
speaks, when we first get thatpotty training right, and they
cry or they share with me, theywent to the movie theater
together and finally were ableto watch the movies and engage
in family outings and they takethe time to give me a call and
(09:37):
tell me how important my workhas been and.
On the other level, a lot oftimes they shared how important
it is for them to feel like apart of the team, that the
supervisor makes them feel likethey're collaborating.
They have something to say aboutwhat's going on in the home,
that they're good at what theydo.
A lot of times technicians wouldsay, I liked it when I felt like
I'm good at it.
(09:58):
and that was also echoed by thesupervisors and the CEOs, this
sense of feeling appreciated fortheir efforts.
A lot of the supervisors wouldshare, same thing back about
their technicians.
When technicians look at themand are feel like I really wanna
do what you do.
How can I learn more?
So supervisors would get veryexcited about families
appreciating them, but alsotheir technicians appreciating
(10:21):
their efforts.
And then of course, theiremployers.
A lot of supervisors shared withme that when their clinical
recommendations are honored orwhen they're called in and
they're asked a little bit moreabout their decisions, not from
a probe and correct perspective,but rather, what led to this
decision making and why are youmaking some of these decisions?
(10:41):
And those are honored as a partof what they provide.
So in a sense of, I'm good atwhat I do, I am heard and I'm
appreciated, was absolutelythings that were shared about
what brought people to the fieldand eventually, I think, a lot
of them came to this point of,and I wanna make change in the
lives of the families we serve,you know, and all of that to the
(11:03):
same path.
and the, flip side of that, uh,was really this very clear
message that sometimes they feltlike pencil pushers, like when
I'm asked to collect data orwhen I'm asked to stay certain
hours the family's home, or whenI'm asked to carry out certain
procedures with the child, itdoesn't feel like this is for
(11:23):
the client or it's makingchange, but I'm being asked to
do these things for some, uh,you know, pencil pushing reason,
and I, don't appreciate it orsupervisors shared that their
efforts could really beminimized over, you know,
dotting the T on some paperworkand all of that clinical effort
(11:43):
could completely go out thewindow and in turn, a lot of
times then the CEOs also sharedthat they, got into their
positions they were excitedabout recruiting talent, growing
talent, but that they too feltlike they were just pencil
pushing, trying to deal withinsurance.
And then dealing with all theerrors in paperwork that trickle
(12:05):
up from their clinicians,because they don't quite
understand the importance ofthat in billing and being able
to keep the organization, movingforward without, constant having
back pay and billing issues.
So I think that that portion ofthe, I don't feel good about
this job is very clear.
I don't wanna be a pencilpusher.
(12:25):
And the other that I think tomyself, these are the times I'm
called in during conflicts andwhich makes perfect sense to me
was really this sense of I don'tseem to matter, I'm a number.
Um, I am just, Replaceable and,I don't feel connected because
what I do and who I am is notnecessarily anything other than
(12:47):
just a, a service to provide forsome end game for someone else.
And that I think, absolutely wassomething that I can see us
addressing a lot better also asa field because I think it's an
issue of communication and howwe create our cultures so
Jonathan (13:04):
Ellie, I confess, I melted when you said early on in
your presentation, you told theaudience behavior is a function
of its circumstances, and youquoted from Dr.
Friman like another hero ofmine, that widespread adoption
of this view would make theworld a better place.
I think that's from 2014 to getDr.
Friman It's so cool.
But like this idea of thebehavior is a function of its
(13:25):
circumstances certainly appliesto burnout and turnover.
and it's something that I think,that ABA practitioners
recognize, like seeing theirday-to-day work with clients.
But why has it been so hard fororganizations to recognize this
vis-a-vis burnout?
Dr. Ellie Kazemi (13:40):
You know, why has it been so hard for
organizations to recognize it?
I think it's because they arealso victims of the context.
it's a vicious cycle.
So organizations, employers, Getcaught up in the billing issues,
billing difficulties, theconstant changes that are coming
their way from the payers.
(14:02):
And the payers are dealing withsome of those things as well
with regards to policies andchanges that are happening.
and I think under thoseconditions, things are hasty.
You're trying to survive as anorganization.
Everyone's moving to survivaland being able to do well.
So I don't think in any way,anyone has mal intent.
(14:22):
I have yet to meet anyone in thefield from investors who come to
the field, they're selecting todo good for the individuals.
They could have put their moneyanywhere.
They often come to the fieldbecause they really want it to
be somewhere that could bemeaningful.
So I have yet to really meetanyone that I'm like, you know,
you have some bad intent.
it really is that they're avictim of those circumstances
(14:43):
and have not had theopportunities to evaluate it.
They've gotten into there overover time and don't even
recognize where they've gottento.
And so the context is for a lotof employers that they are just
in this constant moving, I needto survive.
I need to change things, and Ineed my people to understand and
move with me, help me, you know,move.
(15:07):
And the staff are notnecessarily getting that
communication the same way.
So they feel nothing but rushedchanges and things that are
being trickled down and they'rebeing asked to do things that
they don't quite feel is in linewith their values or what they
joined the organization for.
So I really think that thecontext is, Occurring at
different levels and it's justbecome of a cycle that is not
(15:30):
well communicated.
That's resulting in a lot ofthis conflict I think
Jonathan (15:34):
ellie, that feels deeply insightful'cause it's
almost, uh, I mean the Maslow'shierarchy of needs that pyramid
comes to my mind.
If an organization is fightingfor just pure financial survival
and there's some studies outthere.
Bixby for example, just did ahuge survey of over 60 ABA
providers, it's the secondannual one, and I think they
estimated that like 50% of ABAproviders are either breakeven
(15:54):
or losing money.
Like this stuff can't sustain.
So if organizations are in thisfight for survival, it's hard to
get to higher levels ofunderstanding and compassion and
wanting to make sure to addressthese kinds of burnout issues
like you're describing.
But I mean, what do you think?
Help me, read the Dr.
Ellie Kazemi, like crystal ballhere.
Like what's our field gonna looklike in three to five years when
it comes to clinical servicesand different clinical services
(16:16):
models?
Just knowing that, this idea ofburnout, is not just a short
term trend.
This is a secular trend here tostay.
how do these changes getaddressed by providers?
And can we get back to retentionrates we saw maybe five, 10
years ago?
Or is this truly a big shift instaffing and our field has to
move away from maybe reliance onjust frontline RBTs or maybe
(16:38):
focusing more on BCBA parenttraining only models.
I don't know.
Help me like piece all thistogether.
I
Dr. Ellie Kazemi (16:44):
love it.
I absolutely love it.
And, that is also theentrepreneur in me.
You know, I'm constantly lookingfor new models, and, it's
interesting because as ascientist, I move to solving the
problem from a scienceperspective.
But as an entrepreneur, I moveto the problem and think to
myself, how do I change a createand get out of the box?
So I actually think it's, it'sgonna sound odd, but I think
(17:05):
it's exciting times because Ithink that when we don't
recognize there's a problem,when there is just this shape up
process and we're losing people,we have these explanations of,
ah, people come and go.
But now I think we're in thistime when clearly individuals
want change and conflict to mesets the occasion for some
(17:25):
really good conversations.
Conflict is not a bad thing.
It means that people arerecognizing something is wrong
at every level.
Our supervisors came to thefield invested time to go to
school, invested time to getthose clinical rotations and
internships and supervision.
They don't want to leave.
They want to stay, but they'reat this place of, I'm frustrated
(17:47):
and our CEOs are in the sameposition.
So if you think about it, Ithink that we have to pivot and
we're about to, as a field, Idon't think we can continue
being where we've been andgetting creative about, well,
uh, should we put someone insomeone's home for 30 hours if
we're burning them out whenthere's these elongated hours?
(18:07):
And potentially clients are notproviding, any reinforcing
events because they're exhaustedand everybody's just gotten used
to this person being around.
So those changes that areoccurring don't seem as cool.
We can revisit those models andsay, could we really actually do
this in a more efficient way sothat we can have a better system
(18:28):
for our technicians as well asthe family.
I think getting out of the boxwith regard to some of the
things that you're talkingabout, like, can we think about
some of these models and groups?
Can we think about these thingsa little differently with
regards to how we're providinghours and where our clinicians
are?
Is absolutely upon us, and Ithink we can, and we should.
our model should be pushed.
We have been doing it the sameway, and I think we should be
(18:51):
thinking a little bit more aboutour current model.
I also think that there's someexciting times with, artificial
intelligence here.
Like, you know, it could hearthat you're already having
conversations with Mandy andeverybody else about some of
these things.
And I think that we willabsolutely be able to remove
some of that pencil pushingthings when we begin to automate
(19:11):
and create systems that liftsome of the work from
clinicians, so they're not goingin there retyping date of birth.
Here's, you know, the date of myvisit.
Some of this is populatedbecause there's clear records
and information that can justpopulate itself.
I think that we're gonna beginto see, some of that lifted, and
(19:32):
that's gonna be better.
And then of course, I thinkthat, the fact that we're having
these conversations and, youknow, a lot of organizational
leaders stayed afterwards andhad conversations with me.
I'm getting lots of calls fromindividuals to have these
conversations.
They are realizing that theyneed to be more transparent with
their employees regarding, youknow, this is a vicious cycle.
(19:54):
here's the state I'm in, butyou, the labor force, you the
clinical, supervisors, you aremy lifeline and together we can
turn this or not.
I think that the conversationsshifting and more transparent
conversations about how can wecreate systems that create
better communication and messagebetter to each other, will be
(20:18):
very helpful in the time tocome.
So I think we're gonna have topivot and I don't think we're
alone, Jonathan.
I think we see this inhealthcare.
We see this in veterinary care.
I was, Just, talking to acolleague, you know, my nearby
Ralphs has had to close down abunch of sections because they
don't have enough people.
So we're definitely not alone.
(20:38):
And so I think we are, as asociety, beginning to think a
little bit more about where'sour youth?
What do they want in theirpositions?
How can we make them feel lesslike numbers and more connected?
and I think, behavior analysisis going to make the necessary
shifts.
We have the tools.
Jonathan (20:54):
we absolutely have the tools.
I mean, that's what gets meexcited even in these
challenging times.
But, if we were to zoom up a bitand we look at this like golden
triumvirate of, um, you know,the three critical stakeholders
and services we've been talkingabout one part, the ABA
providers and, team members.
Another critical stakeholder arepayers, and then a third
critical stakeholder obviouslyare families.
(21:15):
so maybe this is a duh kind ofquestion, but are families
experiencing some of the impactsthat all the turnover, retention
and other things, are causingand what are you hearing, if
anything at all from families?
Dr. Ellie Kazemi (21:26):
Yeah, that's an excellent question.
And when I was, working atBHCOE, one of my favorite things
actually was our stakeholderengagement groups with parents
and, individuals on the spectrumthemselves, telling us what they
were looking for in the servicesthat they received, telling us
what were some of the outcomesthey had hoped that were not
(21:46):
achieved.
and.
always, it wouldn't fail thefirst thing they would talk
about is turnover.
Making sure that the individualthat they're getting is someone
that is dependable and, and isshowing up and they saw the
turnover as directly anorganizational problem.
it was a very clear message of,uh, when I'm working with an
(22:08):
organization that the individualis not staying.
They put someone in my homethat's not staying.
I see it as an organizationalproblem.
Jonathan (22:16):
Well, I gotta share, you know, um, when we started
Ascend, gosh, almost six yearsago now, in the first couple
years I would randomly go tofamily, not random.
I'd give heads up, but I wantedto check in with our rbt'cause
we are entirely home-based.
So, you know, I talked to rbt,is, I'd hear lots of feedback
from families.
You know, one of the, IM mostimportant things I heard was, as
(22:37):
an RBT and you're in the homes,10, 20, 30, 40 hours a week.
A family knows you as the RBT.
Mm-hmm.
Not necessarily theorganization.
Exactly.
And you know what a commonquestion or feedback I got from
RBT is families will ask them,how is your employer taking care
of you?
And I think it's reallyimportant not to underestimate
(22:58):
like how powerful thatrelationship is between RBT and
family directly, not necessarilybetween family and organization.
Dr. Ellie Kazemi (23:04):
Right.
I think you made an excellentpoint and I've, I've gotten this
question before actually from,um, organizational leaders,
they'll say, I don't understand.
So when you go to your dentist,you've got the dental
hygienists.
These individuals are not sayingthat, you know, I know a lot of
things to do.
They're working with a team ofindividuals.
I don't understand why ourbehavior technicians feel like
(23:28):
they have such a large role.
There are.
Part of a bigger system, they'rea part of a bigger role, and I
don't understand why they feelso independent and we have to
keep wheeling'em in and itcracks me up because I can
absolutely understand that froma system perspective, there's an
entire system that supports thebehavior technician, right?
There is somebody who dispatcheson someone who's doing the
(23:50):
billing, someone who's providingthe supervision.
But if we take a moment to takeperspective of what the
technician experiences, it's notin an office.
You're not a dental hygienist.
They're not surrounded by thetools and the training and the
material provided to them by theorganization.
They're holding their phonequite often, their personal
phone that they're using for alot of information, and they are
(24:12):
not walking in there in a,sterilized system.
They're walking in someone'shome and how they interact, who
they are, their previousexperiences that brings them to
that moment absolutely matter.
And so they, in many ways arethe frontline and they are the
ones that make all impressionsabout us.
(24:35):
So it makes sense that they feelcompletely like everything rests
on them.
And the flip side of that isthat if we are not providing
them with enough reminders ofthe support and really making
them feel supported when they'reout there, some if they feel
great at the job and they feelgreat on the case, that's fine.
They feel a sense of like, thisis mine, this is what I'm doing.
(24:56):
But in other times, they feelcompletely alone and worried
that they're going to bescapegoated or things will fall
on them.
So I do think the nature of thejob is such that being in
people's private space, inpeople's homes, day in and day
out, seeing how they eat dinner,how they interact with each
other.
How many times can couples orfamily members keep family
(25:16):
fights from a technicianoverseeing it.
I couldn't fake it that good.
Jonathan, I don't know aboutyou, but I can fake it for a
week.
But, you're gonna see some ofthose interactions and, and we
kind of have to realize that'sthe context they're in providing
care.
Jonathan (25:32):
It's so true.
there's no place to hide, right?
you have become as an RBT, likea, effectively, like a
therapeutic member of the familywhile this family's home has
become a therapeutic placeright.
It's, um, it's extraordinary.
Well, let's look at the thirdgroup of critical stakeholders
here, the payers, right?
Insurance companies or Medicaid,who's actually paying for
(25:52):
services.
What are you hearing from payersabout all of this?
Dr. Ellie Kazemi (25:57):
Well, I've been very fortunate to work with
wonderful payers and individualswho equally care about the
families and, have, really a lotof care about organizations
doing well.
And I think, uh, what they'reinterested in and what they
really wanna see more of is,recommendations from the
provider and recommendationsfrom the supervisors that
(26:19):
really, seem to make sense.
Seem to be socially valid forthe families and outcomes that
are achieved, that they canspeak to.
So as the payer, they wanna beable to say, something changed.
I agreed to this, I paid forthis.
I can tangibly hold and say,here's what happened for this
family.
(26:39):
Um, you know, I, I think they'rehighly influenced by, rightfully
so, by parent reports ofoutcomes.
So how caregivers feel about theorganization, how caregivers
feel about how much they'regaining, some of the stories
that they share.
it's incredible because thegrowth of a child, they're not
sharing.
I saw in this report the mostremarkable growth.
(27:04):
Instead, it's the stories thatcaregivers have shared with
them.
Like, here's what occurred forme.
So I think that they're highlyinfluenced by those and want to
see organizations have, betterstandards, better predictions,
be able to really speak to whatthey're able to achieve better.
I would say we're they're at,
Jonathan (27:24):
do you think this, to this idea, Ellie, of better
standards, better organization,better operating systems that
accreditation, whether it'sthrough behavioral health center
of excellence, where you workedor the Autism Commission on
Quality and CASP, like, is, isaccreditation part of the
solution here?
Dr. Ellie Kazemi (27:40):
Well, um, you ask a question of a very biased
person.
I just actually submitted apaper on accreditation and I've
worked, a very long time.
Uh, you know, Eric Dubuque is agreat colleague of mine and so
when Sarah Litvak came to me andasked if I was, joined BHCOE, it
just made sense for me becauseof really, uh, I think that
(28:02):
quality control at every levelhelps.
Because if we are nothing butvictims of our circumstances,
and if circumstance explains ourbehavior, we have to sort of
think about, well, thesupervisor behaviors can be
shaped by what the organizationrequests as well as the board,
right.
The BACB sets guidelines forethical conduct.
The technicians can also haveguidelines and things that their
(28:25):
behaviors are actually undercertain guidance by the
organization as well as by,organizations that oversee them,
who oversees the organization'sbehavior.
If the payer is the onlycontingency, then the payer
requests are always going to besuperseding clinical quality
(28:46):
issues, right?
Because the organization's gonnamove toward billing and the
things that hurt their vitality.
So I see accreditation asnecessary because I can only see
a third objective party being a,a place that provides those
contingencies for anorganization to say, yes, I
realize this is the beststandard in the profession that
(29:07):
I adhere to it.
Jonathan (29:09):
Well, we are in such violent agreement there and as
I've said many times in theshow, I and Ascend are huge fans
of accreditation.
We've been through I think, sixor seven voluntary, BHCOE
accreditation andre-accreditation rounds.
And, with the, I don't know,recent estimates are six to 7000
ABA providers across thecountry.
there have to be certain minimumstandards and that also feels
(29:31):
important when you think about,yes, there are many, BCBAs who
have started and own practicesand there are a lot of practices
that don't have BCBA owners,right?
So therefore, potentially arenot bound by the BACB code of
ethics and exactly all thatcomes with that.
And so that's where it feelsparticularly important that, we
(29:51):
have this like minimum standardand objective set of things that
we've agreed on, lead to ahigher likelihood of the kinds
of outcomes for clients ofoutcomes for our team members of
outcomes, for our payers, forfunders.
that's where it feels reallyimportant to me.
Ellie, who are your heroes inthe field, and what's the most
important thing you've learnedfrom them?
Dr. Ellie Kazemi (30:13):
Oh, uh, We're probably gonna be here for a
bit, uh, on, on that note.
But, probably can begin with PatFriman and one of the reasons
that I, say that, and I have noidea how I came to this man's
attention, but early in mycareer, he, uh, would really be
proud of some of the things thatI'm doing.
(30:34):
and that's how our mentorshiprelationship begun is he would
take time to attend to some ofthe things that I was doing in
my students and he's one of myheroes because what he does, uh,
with regards to youth and hisclinical practice is absolutely,
a great showcasing.
Boystown is a fantastic exampleof what we could do for our
(30:56):
society.
the other thing is that he hassuch a deep respect for our
profession, such a deep respectfor the helping profession, and,
The way that he sees the worldfrom, behavior's a function of
its circumstances, he means it,he applies that to every
circumstance.
(31:16):
And, for all of those reasons,he's one of my heroes.
And no matter how famous he is,and no matter how much you know
he's got on his plates, he'lltake time to let individuals
know, I've witnessed him do thisat conferences where he's seen a
young person present somewhereand he'll take the time to
individually send them a note,look'em up and say, keep that
(31:37):
up.
So I really appreciate that andthat has influenced me a lot in
my career.
Um, I.
I also am deeply influenced byShahla Rosales, and her, social
activism in the field and herdesire to make change at such a
bigger level.
I had the pleasure of seeing alot of her students work and you
know, that application ofbehavior analysis at such a
(32:00):
larger level to solve majorproblems with regards to, what
family's need and just thesocial activist in her I think
is something I aspire to andreally have a lot of respect
for.
And, I think that obviously,outside of that, I could, also
go into talking about AliceDickinson and other, individuals
(32:20):
I have a lot of respect forbecause of my organizational
management, side and the factthat there is a very clear
business organizational mindsetthat those individuals bring to
the profession.
I could sit here for many hours,so that's a very bad question
for Ellie.
Jonathan (32:38):
Well, you know, I, no, I appreciate you sharing some of
your heroes.
I also think it reflects just adeep humility on your part, and
this is What I commonly seeacross extraordinary leaders is
there, there's a humbleness,right, of knowing, the, homage
to, your mentors and heroes andknowing that even as a leader,
There's so much still tocontinue to learn.
Right.
and passing that forward justkind of feels important.
Dr. Ellie Kazemi (33:00):
100%.
Yeah.
and then of course, you know,the mentorship trait, the reason
that question is so tough isbecause you have colleagues that
you respect a lot.
They continue to influence yourwork.
And then I have students thatJonathan, they have absolutely
shifted my career with, greatinput with great, Feedback on
their part.
(33:20):
They have absolutely changed alot of my efforts in, DEI and
being able to really bring thatto BHCOE and also my continued
efforts there were, because Ihad brilliant, wonderful
students who were kind to havereal conversations with me.
So it goes all the way.
Jonathan (33:39):
What an amazing shout out.
Yes.
It goes absolutely both ways.
Well, Ellie, what's one thingABA business owners should start
doing and one thing to stopdoing?
Dr. Ellie Kazemi (33:48):
I think that, one thing that they could do, if
they're not already, is to beginto really message what's
happening for the organization.
I am, absolutely shocked to hearfrom a lot of clinicians or
behavior technicians when Ishare their numbers of what an
organization has to do or whathappens when they budget.
They are absolutely shocked.
(34:10):
they have no idea what it coststo have human resources and
billing.
So I absolutely think thatlearning to message more about
the activities of anorganization so that the
individual realizes that thereis an entire system of support
and what it takes to make itswork together is important.
One thing that they should notdo?
I would say I'm deeplyinfluenced by what individuals
(34:33):
are sharing with me, and that isto never make anyone feel like
they're just a number.
We are at work for more hoursthan we are with our families.
We're at work for more hoursthan we sleep, to join a place
or be a, at a place where youdon't feel you matter.
I don't think anybody would giveus their best under those
(34:53):
conditions.
None of us said, I wanna grow upto be a number somewhere.
You know, I don't, I don't thinkanyone aspires to that, and I do
think that we make thosemistakes.
So taking time to think, how canI make my people not feel like
just another number is gonna bereally important?
Jonathan (35:10):
Amen to that.
I mean, what you just said, liketaking time, right, is just
pause in the moment and bepresent as you have
conversations, and don't thinkabout those interactions as, you
know, checking off the latestmeeting and, checking off the
boxes, but truly being deeplypresent.
Well, Ellie, where can peoplefind you online?
Dr. Ellie Kazemi (35:28):
Well, um, I am excited in my new journey.
I'm actually, looking reallyinto self-reflective practice
and I've developed some toolsfor some time that I've been
working with organizations doingconsulting.
And, I'm going to move all ofthat into my new, uh, work.
And so you can find me atelliekazemi.com and I'm just
(35:50):
building those out.
so if you go there, you'll findbunch of pages that are just
new.
I've done a lot of consultationsfor organizations over the
years, but I've never actually,matriculated them into
formalized assessment proceduresfor individuals to be able to
access.
My goal is to formalize and, andmake everything accessible in
the, upcoming year.
Jonathan (36:09):
I love it, Ellie, just another way you are paying it
forward in our field.
Well, are you ready for the hottake questions?
Dr. Ellie Kazemi (36:16):
I sure am.
Jonathan (36:18):
All right, Ellie, you're on your deathbed.
What's the one thing you wannabe remembered for,
Dr. Ellie Kazemi (36:22):
uh, being a strong family member?
Jonathan (36:26):
What's your most important self-care practice?
Dr. Ellie Kazemi (36:29):
Turning it on and off.
Jonathan (36:32):
Woo.
Say more about that.
I love that.
Dr. Ellie Kazemi (36:35):
Uh, learning to be present, you know, this
is, this is work.
I love my job very much.
It's also a passion, butlearning to turn it off when I'm
spending time with my nieces orwith my son and turning the
pressures or the stressors ofwhat's happening there off when
I'm elsewhere, so that it's notleaking over.
So, mindful practice to learn,to continue to turn it on and
(36:58):
off is, yeah.
Jonathan (37:00):
So powerful.
Please include that in this setof organizational tools.
Leaders can like develop betterrepertoires around.
That feels really important.
What's your favorite song and ormusic genre?
Dr. Ellie Kazemi (37:14):
You know, this is gonna sound really corny.
So I grew up listening to LedZeppelin'cause my dad loved that
era.
And, you know, I absolutely am aQueen fan.
And, so I, I actually like a lotof the pop, um, Sort of, heavy
metal like Metallica.
Um, so those are,
Jonathan (37:35):
we are kindred spirits on that.
Metallica just came out with anew album, 72 seasons.
I do not believe they are stilldoing it.
Wow.
I wish I had a 10th of theirenergy.
Right.
What's one thing you'd tell your18 year old self Ellie?
Dr. Ellie Kazemi (37:48):
I would say know that you know nothing and
that you'll change your mind allthe time, and that change is
cool and awesome and that you'llneed to ride unchanged.
Don't be so fixed.
Jonathan (38:06):
Well, if you could only wear one style of footwear,
what would it be?
Dr. Ellie Kazemi (38:09):
Oh, oh my God.
I wish I had prepared for thisquestion.
I can't even, I can't even thinkof what that would be.
It would be cool and weird withreally weird heels, but I can't
think of the name I like, I likethings that are retro.
Jonathan (38:26):
I love it.
Cool and weird with really weirdheels.
Boom.
There.
Well, Ellie, thank you so muchfor taking time to catch up and
for sharing your wisdom with ourfield.
I appreciate you.
Dr. Ellie Kazemi (38:38):
I appreciate you back.
Thank you.
My guest today is Dr.
Ellie Kazemi.
Dr.
Kazemi merges behavioralscience, advanced technology and
database decision making withmany years of experience working
with leadership to promotestrong organizational cultures,
practical and efficienttraining, and transparent
messaging and communication.
She's a tenure track professorat CSUN, where she founded the
MS in Applied Behavior Analysisprogram in 2010, and teaches
(00:52):
undergraduate and graduatecoursework in organizational
management and behavioralanalysis.
She's also served as the chiefscience officer at the
Behavioral Health Center ofExcellence, BHCOE, an
accrediting organization whereshe oversaw standard
development, evaluationmethodology, measurement
science, and thought leadership.
Ellie, welcome to the pod.
Dr. Ellie Kazemi (01:12):
Thank you.
It's nice to be here.
Jonathan (01:14):
Alright, this is so topical.
We're recording this, not onlyon today.
April 27th is a day withouthate, but it's, um, almost
exactly one week after I got tosee you at the Autism Investor
Summit.
And I was sitting in the frontrow and just like grinning ear
to ear on all of the data youwere sharing, about burnout and
what makes people stay andretention and turnover and all
(01:35):
kinds of stuff.
And so, it's an honor to haveyou here, Ellie, and let's start
with what got you so interestedin learning more about provider
burnout and retention.
Dr. Ellie Kazemi (01:43):
Well, um, I've been interested in that for some
time.
I think when we put out theturnover paper, it was like
2010, we were beginning torealize that there is such a,
incredible amount of turnover inthat behavior technician level.
Um, and I think that, In anyprofession, what you're
interested in is why are peopleleaving?
because you want to do somethingabout that.
(02:04):
And you know the people that areleaving for good reasons.
You want to encourage'em on andbe happy about that and, get
them to a better place.
But if people are leavingbecause you're not doing
something right or you just needto change your messaging or you
need to change the culture ofwhat you're doing.
Those things I think are doableand good feedback for us as a
community.
(02:24):
So I've been interested in thistopic, at many different levels,
and I think more interesting isprobably post covid, how
everyone else has gained so muchinterest in the area.
So I feel like I've kind of beenwatching this rise in turnover
and likelihood to quit, but, Ithink that Covid sort of made us
(02:45):
all very aware that we have aproblem.
Jonathan (02:48):
Yeah.
Let's go deeper on that.
'cause one of the things Itotally didn't appreciate until
I saw it in your presentation,and there's a Harvard Business
Review article you highlighted,called The Great Resignation
Didn't start with Covid.
Tell me more.
Dr. Ellie Kazemi (03:03):
Yeah.
You know, I thought HarvardBusiness Review did such an
awesome job with this, wherethey showed that this
progressive graph showed veryclearly that what we're seeing
is a rise in, voluntary turnoverand silent quitting from
individuals, but that because ofjob insecurities or people
worrying about furloughs andwhatnot during Covid, there was
(03:25):
actually a period of time whenpeople were keeping their jobs,
so right afterwards weexperienced what we would've
typically experienced as thenext rise, but it just feels
like so much more.
And I think that that is exactlywhy I've been interested in,
turnover and burnout for sometime because we're seeing it and
we're seeing it progressively,but it's only human.
(03:47):
When something happens justslightly a little bit more every
time there's a shaping process,we don't feel it's happening.
Um, and so I think it's reallygiving us some time to think
about this, uh, which isimportant.
Jonathan (03:59):
Yeah, and it shows, I, I think just a fundamentally
different sort of nature ofcontract between employee and
employer than we've experiencedin the past.
And that we, we may or may not,right, as organizations or
specifically as ABA providershave tools that we're equipped
to address that.
But of the many things that wereso powerful about your
presentation is you shared someof the data with your
(04:20):
conversations with, I think itwas like, 250 RBT and BCBAs in
which you listened and you haddirect conversations with them
about what they love feeling andseeing in their jobs, what keeps
them coming to work, and alsowhat burns them out.
Tell me more about yourfindings.
Dr. Ellie Kazemi (04:37):
Yeah, I love that because I think what
happened for me was, wheneveryone started to recognize
this as an issue, and you know,our turnover paper had been
there.
People had looked at it before.
But then more than ever, I'mgetting notifications from
ResearchGate that people areactually looking that paper up
now, post Covid.
I really wanted to shift thefocus'cause it's important if we
(04:58):
see Covid as the cause or themajor explanation, if something
happened during Covid, we'relikely to look at different
things than what is itprogressively that we're doing
as corporations, asorganizations, as employers that
may potentially be resulting ina higher and higher level of
individuals leaving.
And I think it, that shiftingthat focus is really important,
(05:20):
uh, from my perspective.
so I put out a call and I'vebeen hearing from a lot of
individuals, that we'vegraduated over the years, we've
graduated over 400 BCBAs fromthe Cal State Northridge
program.
And I can't even say how manybehavior technicians'cause each
semester alone I teach 300students or so.
(05:40):
So we absolutely have our ownbase of individuals who were
contacting me, talking to meabout changing jobs, leaving the
profession as a whole, and Ididn't want the sample to just
be the individuals that we hadgraduated or that came to CSUN.
So I posted on social media,believe it or not, just, Hey, if
you wanna talk about, yourprofession, if this is not what
(06:02):
you envisioned.
gimme a call, text me or send mesomething.
And the number of individualswho wanted to speak just blew me
away.
They, reached out, they wouldsend me such personal
informations, they would writeout what felt like just these
events in their lives that theyhad sat down and thought about
(06:24):
the vulnerability was prettyincredible.
And the other part of what wasincredible was that I had not
said, you know, hey supervisors,I assumed who I was speaking to
was supervisors.
but actually I received callsand requests to speak from CEOs,
from, uh, academicians, frombehavior technicians.
(06:46):
So it was definitely across,positions where they wanted to
talk about what they thought theprofession would be, why they
came to it, what they loved andwhat was changing for them, or
why they were seeking somethingelse.
so I was able to synthesizeacross those stories and what
(07:06):
became very clear to me when youspeak to over 250 people, is the
similarities, the universaltruths come up.
Right?
so I think that that's beenvery, uh, very cool.
In my history, I've not donethat much qualitative research,
but I can definitely see thevalue in having spoken to
people, cause what I didn'twanna do, Jonathan, is to put
out a call and say, Hey, are youburned out?
(07:28):
Tell me more about your feelingsof burnout, because we know that
that's been done to teachereducation, and all it does is it
burns people out.
so I wanted folks to, to connectback to why they're here, and
tell me how we could get there.
Jonathan (07:45):
So I'm, I'm like on the edge of my seat.
You gotta share some of theuniversal truths that you were
hearing.
Uh, I remember in particular,like stories about a behavior
technician, for example, who waslike expected to go into this
really challenging situationwith a kiddo in bed and yeah.
Tell me more about the universaltruths.
Dr. Ellie Kazemi (08:03):
Yeah.
so, I don't think we have enoughtime for me to share with you
the personal stories at thoselevels.
I selected stories ofindividuals that I felt really
were echoed across thetechnician and the supervisor,
and then of course the CEOs.
Um, and I wanted thesimilarities to emerge and I
think for the most part it'svery clear that people came to
(08:28):
the clinical portion of ourfield from a desire to change
things, to be able to be aneffective agent of change, I
want to be able to helpfamilies.
many individuals shared thoseexact moments where they fell in
love and it was typically fellin love with a client or fell in
love with, um, like our CEOs,would talk more about these
(08:51):
moments of feeling like theycould make a difference in the
lives of their employees whenthey watch them blossom.
And so there were clearly thesemoments of, I want to help and
when I see that change, when Iget to access being effective,
that feels great.
Uh, and that was definitelyuniversal.
Um, the other was, Feelingappreciated.
(09:14):
Which was interesting becausethe technicians spoke about
appreciation more from theperspective of when the families
want me around, when they arethankful when their child
speaks, when we first get thatpotty training right, and they
cry or they share with me, theywent to the movie theater
together and finally were ableto watch the movies and engage
in family outings and they takethe time to give me a call and
(09:37):
tell me how important my workhas been and.
On the other level, a lot oftimes they shared how important
it is for them to feel like apart of the team, that the
supervisor makes them feel likethey're collaborating.
They have something to say aboutwhat's going on in the home,
that they're good at what theydo.
A lot of times technicians wouldsay, I liked it when I felt like
I'm good at it.
(09:58):
and that was also echoed by thesupervisors and the CEOs, this
sense of feeling appreciated fortheir efforts.
A lot of the supervisors wouldshare, same thing back about
their technicians.
When technicians look at themand are feel like I really wanna
do what you do.
How can I learn more?
So supervisors would get veryexcited about families
appreciating them, but alsotheir technicians appreciating
(10:21):
their efforts.
And then of course, theiremployers.
A lot of supervisors shared withme that when their clinical
recommendations are honored orwhen they're called in and
they're asked a little bit moreabout their decisions, not from
a probe and correct perspective,but rather, what led to this
decision making and why are youmaking some of these decisions?
(10:41):
And those are honored as a partof what they provide.
So in a sense of, I'm good atwhat I do, I am heard and I'm
appreciated, was absolutelythings that were shared about
what brought people to the fieldand eventually, I think, a lot
of them came to this point of,and I wanna make change in the
lives of the families we serve,you know, and all of that to the
(11:03):
same path.
and the, flip side of that, uh,was really this very clear
message that sometimes they feltlike pencil pushers, like when
I'm asked to collect data orwhen I'm asked to stay certain
hours the family's home, or whenI'm asked to carry out certain
procedures with the child, itdoesn't feel like this is for
(11:23):
the client or it's makingchange, but I'm being asked to
do these things for some, uh,you know, pencil pushing reason,
and I, don't appreciate it orsupervisors shared that their
efforts could really beminimized over, you know,
dotting the T on some paperworkand all of that clinical effort
(11:43):
could completely go out thewindow and in turn, a lot of
times then the CEOs also sharedthat they, got into their
positions they were excitedabout recruiting talent, growing
talent, but that they too feltlike they were just pencil
pushing, trying to deal withinsurance.
And then dealing with all theerrors in paperwork that trickle
(12:05):
up from their clinicians,because they don't quite
understand the importance ofthat in billing and being able
to keep the organization, movingforward without, constant having
back pay and billing issues.
So I think that that portion ofthe, I don't feel good about
this job is very clear.
I don't wanna be a pencilpusher.
(12:25):
And the other that I think tomyself, these are the times I'm
called in during conflicts andwhich makes perfect sense to me
was really this sense of I don'tseem to matter, I'm a number.
Um, I am just, Replaceable and,I don't feel connected because
what I do and who I am is notnecessarily anything other than
(12:47):
just a, a service to provide forsome end game for someone else.
And that I think, absolutely wassomething that I can see us
addressing a lot better also asa field because I think it's an
issue of communication and howwe create our cultures so
Jonathan (13:04):
Ellie, I confess, I melted when you said early on in
your presentation, you told theaudience behavior is a function
of its circumstances, and youquoted from Dr.
Friman like another hero ofmine, that widespread adoption
of this view would make theworld a better place.
I think that's from 2014 to getDr.
Friman It's so cool.
But like this idea of thebehavior is a function of its
(13:25):
circumstances certainly appliesto burnout and turnover.
and it's something that I think,that ABA practitioners
recognize, like seeing theirday-to-day work with clients.
But why has it been so hard fororganizations to recognize this
vis-a-vis burnout?
Dr. Ellie Kazemi (13:40):
You know, why has it been so hard for
organizations to recognize it?
I think it's because they arealso victims of the context.
it's a vicious cycle.
So organizations, employers, Getcaught up in the billing issues,
billing difficulties, theconstant changes that are coming
their way from the payers.
(14:02):
And the payers are dealing withsome of those things as well
with regards to policies andchanges that are happening.
and I think under thoseconditions, things are hasty.
You're trying to survive as anorganization.
Everyone's moving to survivaland being able to do well.
So I don't think in any way,anyone has mal intent.
(14:22):
I have yet to meet anyone in thefield from investors who come to
the field, they're selecting todo good for the individuals.
They could have put their moneyanywhere.
They often come to the fieldbecause they really want it to
be somewhere that could bemeaningful.
So I have yet to really meetanyone that I'm like, you know,
you have some bad intent.
it really is that they're avictim of those circumstances
(14:43):
and have not had theopportunities to evaluate it.
They've gotten into there overover time and don't even
recognize where they've gottento.
And so the context is for a lotof employers that they are just
in this constant moving, I needto survive.
I need to change things, and Ineed my people to understand and
move with me, help me, you know,move.
(15:07):
And the staff are notnecessarily getting that
communication the same way.
So they feel nothing but rushedchanges and things that are
being trickled down and they'rebeing asked to do things that
they don't quite feel is in linewith their values or what they
joined the organization for.
So I really think that thecontext is, Occurring at
different levels and it's justbecome of a cycle that is not
(15:30):
well communicated.
That's resulting in a lot ofthis conflict I think
Jonathan (15:34):
ellie, that feels deeply insightful'cause it's
almost, uh, I mean the Maslow'shierarchy of needs that pyramid
comes to my mind.
If an organization is fightingfor just pure financial survival
and there's some studies outthere.
Bixby for example, just did ahuge survey of over 60 ABA
providers, it's the secondannual one, and I think they
estimated that like 50% of ABAproviders are either breakeven
(15:54):
or losing money.
Like this stuff can't sustain.
So if organizations are in thisfight for survival, it's hard to
get to higher levels ofunderstanding and compassion and
wanting to make sure to addressthese kinds of burnout issues
like you're describing.
But I mean, what do you think?
Help me, read the Dr.
Ellie Kazemi, like crystal ballhere.
Like what's our field gonna looklike in three to five years when
it comes to clinical servicesand different clinical services
(16:16):
models?
Just knowing that, this idea ofburnout, is not just a short
term trend.
This is a secular trend here tostay.
how do these changes getaddressed by providers?
And can we get back to retentionrates we saw maybe five, 10
years ago?
Or is this truly a big shift instaffing and our field has to
move away from maybe reliance onjust frontline RBTs or maybe
(16:38):
focusing more on BCBA parenttraining only models.
I don't know.
Help me like piece all thistogether.
I
Dr. Ellie Kazemi (16:44):
love it.
I absolutely love it.
And, that is also theentrepreneur in me.
You know, I'm constantly lookingfor new models, and, it's
interesting because as ascientist, I move to solving the
problem from a scienceperspective.
But as an entrepreneur, I moveto the problem and think to
myself, how do I change a createand get out of the box?
So I actually think it's, it'sgonna sound odd, but I think
(17:05):
it's exciting times because Ithink that when we don't
recognize there's a problem,when there is just this shape up
process and we're losing people,we have these explanations of,
ah, people come and go.
But now I think we're in thistime when clearly individuals
want change and conflict to mesets the occasion for some
(17:25):
really good conversations.
Conflict is not a bad thing.
It means that people arerecognizing something is wrong
at every level.
Our supervisors came to thefield invested time to go to
school, invested time to getthose clinical rotations and
internships and supervision.
They don't want to leave.
They want to stay, but they'reat this place of, I'm frustrated
(17:47):
and our CEOs are in the sameposition.
So if you think about it, Ithink that we have to pivot and
we're about to, as a field, Idon't think we can continue
being where we've been andgetting creative about, well,
uh, should we put someone insomeone's home for 30 hours if
we're burning them out whenthere's these elongated hours?
(18:07):
And potentially clients are notproviding, any reinforcing
events because they're exhaustedand everybody's just gotten used
to this person being around.
So those changes that areoccurring don't seem as cool.
We can revisit those models andsay, could we really actually do
this in a more efficient way sothat we can have a better system
(18:28):
for our technicians as well asthe family.
I think getting out of the boxwith regard to some of the
things that you're talkingabout, like, can we think about
some of these models and groups?
Can we think about these thingsa little differently with
regards to how we're providinghours and where our clinicians
are?
Is absolutely upon us, and Ithink we can, and we should.
our model should be pushed.
We have been doing it the sameway, and I think we should be
(18:51):
thinking a little bit more aboutour current model.
I also think that there's someexciting times with, artificial
intelligence here.
Like, you know, it could hearthat you're already having
conversations with Mandy andeverybody else about some of
these things.
And I think that we willabsolutely be able to remove
some of that pencil pushingthings when we begin to automate
(19:11):
and create systems that liftsome of the work from
clinicians, so they're not goingin there retyping date of birth.
Here's, you know, the date of myvisit.
Some of this is populatedbecause there's clear records
and information that can justpopulate itself.
I think that we're gonna beginto see, some of that lifted, and
(19:32):
that's gonna be better.
And then of course, I thinkthat, the fact that we're having
these conversations and, youknow, a lot of organizational
leaders stayed afterwards andhad conversations with me.
I'm getting lots of calls fromindividuals to have these
conversations.
They are realizing that theyneed to be more transparent with
their employees regarding, youknow, this is a vicious cycle.
(19:54):
here's the state I'm in, butyou, the labor force, you the
clinical, supervisors, you aremy lifeline and together we can
turn this or not.
I think that the conversationsshifting and more transparent
conversations about how can wecreate systems that create
better communication and messagebetter to each other, will be
(20:18):
very helpful in the time tocome.
So I think we're gonna have topivot and I don't think we're
alone, Jonathan.
I think we see this inhealthcare.
We see this in veterinary care.
I was, Just, talking to acolleague, you know, my nearby
Ralphs has had to close down abunch of sections because they
don't have enough people.
So we're definitely not alone.
(20:38):
And so I think we are, as asociety, beginning to think a
little bit more about where'sour youth?
What do they want in theirpositions?
How can we make them feel lesslike numbers and more connected?
and I think, behavior analysisis going to make the necessary
shifts.
We have the tools.
Jonathan (20:54):
we absolutely have the tools.
I mean, that's what gets meexcited even in these
challenging times.
But, if we were to zoom up a bitand we look at this like golden
triumvirate of, um, you know,the three critical stakeholders
and services we've been talkingabout one part, the ABA
providers and, team members.
Another critical stakeholder arepayers, and then a third
critical stakeholder obviouslyare families.
(21:15):
so maybe this is a duh kind ofquestion, but are families
experiencing some of the impactsthat all the turnover, retention
and other things, are causingand what are you hearing, if
anything at all from families?
Dr. Ellie Kazemi (21:26):
Yeah, that's an excellent question.
And when I was, working atBHCOE, one of my favorite things
actually was our stakeholderengagement groups with parents
and, individuals on the spectrumthemselves, telling us what they
were looking for in the servicesthat they received, telling us
what were some of the outcomesthey had hoped that were not
(21:46):
achieved.
and.
always, it wouldn't fail thefirst thing they would talk
about is turnover.
Making sure that the individualthat they're getting is someone
that is dependable and, and isshowing up and they saw the
turnover as directly anorganizational problem.
it was a very clear message of,uh, when I'm working with an
(22:08):
organization that the individualis not staying.
They put someone in my homethat's not staying.
I see it as an organizationalproblem.
Jonathan (22:16):
Well, I gotta share, you know, um, when we started
Ascend, gosh, almost six yearsago now, in the first couple
years I would randomly go tofamily, not random.
I'd give heads up, but I wantedto check in with our rbt'cause
we are entirely home-based.
So, you know, I talked to rbt,is, I'd hear lots of feedback
from families.
You know, one of the, IM mostimportant things I heard was, as
(22:37):
an RBT and you're in the homes,10, 20, 30, 40 hours a week.
A family knows you as the RBT.
Mm-hmm.
Not necessarily theorganization.
Exactly.
And you know what a commonquestion or feedback I got from
RBT is families will ask them,how is your employer taking care
of you?
And I think it's reallyimportant not to underestimate
(22:58):
like how powerful thatrelationship is between RBT and
family directly, not necessarilybetween family and organization.
Dr. Ellie Kazemi (23:04):
Right.
I think you made an excellentpoint and I've, I've gotten this
question before actually from,um, organizational leaders,
they'll say, I don't understand.
So when you go to your dentist,you've got the dental
hygienists.
These individuals are not sayingthat, you know, I know a lot of
things to do.
They're working with a team ofindividuals.
I don't understand why ourbehavior technicians feel like
(23:28):
they have such a large role.
There are.
Part of a bigger system, they'rea part of a bigger role, and I
don't understand why they feelso independent and we have to
keep wheeling'em in and itcracks me up because I can
absolutely understand that froma system perspective, there's an
entire system that supports thebehavior technician, right?
There is somebody who dispatcheson someone who's doing the
(23:50):
billing, someone who's providingthe supervision.
But if we take a moment to takeperspective of what the
technician experiences, it's notin an office.
You're not a dental hygienist.
They're not surrounded by thetools and the training and the
material provided to them by theorganization.
They're holding their phonequite often, their personal
phone that they're using for alot of information, and they are
(24:12):
not walking in there in a,sterilized system.
They're walking in someone'shome and how they interact, who
they are, their previousexperiences that brings them to
that moment absolutely matter.
And so they, in many ways arethe frontline and they are the
ones that make all impressionsabout us.
(24:35):
So it makes sense that they feelcompletely like everything rests
on them.
And the flip side of that isthat if we are not providing
them with enough reminders ofthe support and really making
them feel supported when they'reout there, some if they feel
great at the job and they feelgreat on the case, that's fine.
They feel a sense of like, thisis mine, this is what I'm doing.
(24:56):
But in other times, they feelcompletely alone and worried
that they're going to bescapegoated or things will fall
on them.
So I do think the nature of thejob is such that being in
people's private space, inpeople's homes, day in and day
out, seeing how they eat dinner,how they interact with each
other.
How many times can couples orfamily members keep family
(25:16):
fights from a technicianoverseeing it.
I couldn't fake it that good.
Jonathan, I don't know aboutyou, but I can fake it for a
week.
But, you're gonna see some ofthose interactions and, and we
kind of have to realize that'sthe context they're in providing
care.
Jonathan (25:32):
It's so true.
there's no place to hide, right?
you have become as an RBT, likea, effectively, like a
therapeutic member of the familywhile this family's home has
become a therapeutic placeright.
It's, um, it's extraordinary.
Well, let's look at the thirdgroup of critical stakeholders
here, the payers, right?
Insurance companies or Medicaid,who's actually paying for
(25:52):
services.
What are you hearing from payersabout all of this?
Dr. Ellie Kazemi (25:57):
Well, I've been very fortunate to work with
wonderful payers and individualswho equally care about the
families and, have, really a lotof care about organizations
doing well.
And I think, uh, what they'reinterested in and what they
really wanna see more of is,recommendations from the
provider and recommendationsfrom the supervisors that
(26:19):
really, seem to make sense.
Seem to be socially valid forthe families and outcomes that
are achieved, that they canspeak to.
So as the payer, they wanna beable to say, something changed.
I agreed to this, I paid forthis.
I can tangibly hold and say,here's what happened for this
family.
(26:39):
Um, you know, I, I think they'rehighly influenced by, rightfully
so, by parent reports ofoutcomes.
So how caregivers feel about theorganization, how caregivers
feel about how much they'regaining, some of the stories
that they share.
it's incredible because thegrowth of a child, they're not
sharing.
I saw in this report the mostremarkable growth.
(27:04):
Instead, it's the stories thatcaregivers have shared with
them.
Like, here's what occurred forme.
So I think that they're highlyinfluenced by those and want to
see organizations have, betterstandards, better predictions,
be able to really speak to whatthey're able to achieve better.
I would say we're they're at,
Jonathan (27:24):
do you think this, to this idea, Ellie, of better
standards, better organization,better operating systems that
accreditation, whether it'sthrough behavioral health center
of excellence, where you workedor the Autism Commission on
Quality and CASP, like, is, isaccreditation part of the
solution here?
Dr. Ellie Kazemi (27:40):
Well, um, you ask a question of a very biased
person.
I just actually submitted apaper on accreditation and I've
worked, a very long time.
Uh, you know, Eric Dubuque is agreat colleague of mine and so
when Sarah Litvak came to me andasked if I was, joined BHCOE, it
just made sense for me becauseof really, uh, I think that
(28:02):
quality control at every levelhelps.
Because if we are nothing butvictims of our circumstances,
and if circumstance explains ourbehavior, we have to sort of
think about, well, thesupervisor behaviors can be
shaped by what the organizationrequests as well as the board,
right.
The BACB sets guidelines forethical conduct.
The technicians can also haveguidelines and things that their
(28:25):
behaviors are actually undercertain guidance by the
organization as well as by,organizations that oversee them,
who oversees the organization'sbehavior.
If the payer is the onlycontingency, then the payer
requests are always going to besuperseding clinical quality
(28:46):
issues, right?
Because the organization's gonnamove toward billing and the
things that hurt their vitality.
So I see accreditation asnecessary because I can only see
a third objective party being a,a place that provides those
contingencies for anorganization to say, yes, I
realize this is the beststandard in the profession that
(29:07):
I adhere to it.
Jonathan (29:09):
Well, we are in such violent agreement there and as
I've said many times in theshow, I and Ascend are huge fans
of accreditation.
We've been through I think, sixor seven voluntary, BHCOE
accreditation andre-accreditation rounds.
And, with the, I don't know,recent estimates are six to 7000
ABA providers across thecountry.
there have to be certain minimumstandards and that also feels
(29:31):
important when you think about,yes, there are many, BCBAs who
have started and own practicesand there are a lot of practices
that don't have BCBA owners,right?
So therefore, potentially arenot bound by the BACB code of
ethics and exactly all thatcomes with that.
And so that's where it feelsparticularly important that, we
(29:51):
have this like minimum standardand objective set of things that
we've agreed on, lead to ahigher likelihood of the kinds
of outcomes for clients ofoutcomes for our team members of
outcomes, for our payers, forfunders.
that's where it feels reallyimportant to me.
Ellie, who are your heroes inthe field, and what's the most
important thing you've learnedfrom them?
Dr. Ellie Kazemi (30:13):
Oh, uh, We're probably gonna be here for a
bit, uh, on, on that note.
But, probably can begin with PatFriman and one of the reasons
that I, say that, and I have noidea how I came to this man's
attention, but early in mycareer, he, uh, would really be
proud of some of the things thatI'm doing.
(30:34):
and that's how our mentorshiprelationship begun is he would
take time to attend to some ofthe things that I was doing in
my students and he's one of myheroes because what he does, uh,
with regards to youth and hisclinical practice is absolutely,
a great showcasing.
Boystown is a fantastic exampleof what we could do for our
(30:56):
society.
the other thing is that he hassuch a deep respect for our
profession, such a deep respectfor the helping profession, and,
The way that he sees the worldfrom, behavior's a function of
its circumstances, he means it,he applies that to every
circumstance.
(31:16):
And, for all of those reasons,he's one of my heroes.
And no matter how famous he is,and no matter how much you know
he's got on his plates, he'lltake time to let individuals
know, I've witnessed him do thisat conferences where he's seen a
young person present somewhereand he'll take the time to
individually send them a note,look'em up and say, keep that
(31:37):
up.
So I really appreciate that andthat has influenced me a lot in
my career.
Um, I.
I also am deeply influenced byShahla Rosales, and her, social
activism in the field and herdesire to make change at such a
bigger level.
I had the pleasure of seeing alot of her students work and you
know, that application ofbehavior analysis at such a
(32:00):
larger level to solve majorproblems with regards to, what
family's need and just thesocial activist in her I think
is something I aspire to andreally have a lot of respect
for.
And, I think that obviously,outside of that, I could, also
go into talking about AliceDickinson and other, individuals
(32:20):
I have a lot of respect forbecause of my organizational
management, side and the factthat there is a very clear
business organizational mindsetthat those individuals bring to
the profession.
I could sit here for many hours,so that's a very bad question
for Ellie.
Jonathan (32:38):
Well, you know, I, no, I appreciate you sharing some of
your heroes.
I also think it reflects just adeep humility on your part, and
this is What I commonly seeacross extraordinary leaders is
there, there's a humbleness,right, of knowing, the, homage
to, your mentors and heroes andknowing that even as a leader,
There's so much still tocontinue to learn.
Right.
and passing that forward justkind of feels important.
Dr. Ellie Kazemi (33:00):
100%.
Yeah.
and then of course, you know,the mentorship trait, the reason
that question is so tough isbecause you have colleagues that
you respect a lot.
They continue to influence yourwork.
And then I have students thatJonathan, they have absolutely
shifted my career with, greatinput with great, Feedback on
their part.
(33:20):
They have absolutely changed alot of my efforts in, DEI and
being able to really bring thatto BHCOE and also my continued
efforts there were, because Ihad brilliant, wonderful
students who were kind to havereal conversations with me.
So it goes all the way.
Jonathan (33:39):
What an amazing shout out.
Yes.
It goes absolutely both ways.
Well, Ellie, what's one thingABA business owners should start
doing and one thing to stopdoing?
Dr. Ellie Kazemi (33:48):
I think that, one thing that they could do, if
they're not already, is to beginto really message what's
happening for the organization.
I am, absolutely shocked to hearfrom a lot of clinicians or
behavior technicians when Ishare their numbers of what an
organization has to do or whathappens when they budget.
They are absolutely shocked.
(34:10):
they have no idea what it coststo have human resources and
billing.
So I absolutely think thatlearning to message more about
the activities of anorganization so that the
individual realizes that thereis an entire system of support
and what it takes to make itswork together is important.
One thing that they should notdo?
I would say I'm deeplyinfluenced by what individuals
(34:33):
are sharing with me, and that isto never make anyone feel like
they're just a number.
We are at work for more hoursthan we are with our families.
We're at work for more hoursthan we sleep, to join a place
or be a, at a place where youdon't feel you matter.
I don't think anybody would giveus their best under those
(34:53):
conditions.
None of us said, I wanna grow upto be a number somewhere.
You know, I don't, I don't thinkanyone aspires to that, and I do
think that we make thosemistakes.
So taking time to think, how canI make my people not feel like
just another number is gonna bereally important?
Jonathan (35:10):
Amen to that.
I mean, what you just said, liketaking time, right, is just
pause in the moment and bepresent as you have
conversations, and don't thinkabout those interactions as, you
know, checking off the latestmeeting and, checking off the
boxes, but truly being deeplypresent.
Well, Ellie, where can peoplefind you online?
Dr. Ellie Kazemi (35:28):
Well, um, I am excited in my new journey.
I'm actually, looking reallyinto self-reflective practice
and I've developed some toolsfor some time that I've been
working with organizations doingconsulting.
And, I'm going to move all ofthat into my new, uh, work.
And so you can find me atelliekazemi.com and I'm just
(35:50):
building those out.
so if you go there, you'll findbunch of pages that are just
new.
I've done a lot of consultationsfor organizations over the
years, but I've never actually,matriculated them into
formalized assessment proceduresfor individuals to be able to
access.
My goal is to formalize and, andmake everything accessible in
the, upcoming year.
Jonathan (36:09):
I love it, Ellie, just another way you are paying it
forward in our field.
Well, are you ready for the hottake questions?
Dr. Ellie Kazemi (36:16):
I sure am.
Jonathan (36:18):
All right, Ellie, you're on your deathbed.
What's the one thing you wannabe remembered for,
Dr. Ellie Kazemi (36:22):
uh, being a strong family member?
Jonathan (36:26):
What's your most important self-care practice?
Dr. Ellie Kazemi (36:29):
Turning it on and off.
Jonathan (36:32):
Woo.
Say more about that.
I love that.
Dr. Ellie Kazemi (36:35):
Uh, learning to be present, you know, this
is, this is work.
I love my job very much.
It's also a passion, butlearning to turn it off when I'm
spending time with my nieces orwith my son and turning the
pressures or the stressors ofwhat's happening there off when
I'm elsewhere, so that it's notleaking over.
So, mindful practice to learn,to continue to turn it on and
(36:58):
off is, yeah.
Jonathan (37:00):
So powerful.
Please include that in this setof organizational tools.
Leaders can like develop betterrepertoires around.
That feels really important.
What's your favorite song and ormusic genre?
Dr. Ellie Kazemi (37:14):
You know, this is gonna sound really corny.
So I grew up listening to LedZeppelin'cause my dad loved that
era.
And, you know, I absolutely am aQueen fan.
And, so I, I actually like a lotof the pop, um, Sort of, heavy
metal like Metallica.
Um, so those are,
Jonathan (37:35):
we are kindred spirits on that.
Metallica just came out with anew album, 72 seasons.
I do not believe they are stilldoing it.
Wow.
I wish I had a 10th of theirenergy.
Right.
What's one thing you'd tell your18 year old self Ellie?
Dr. Ellie Kazemi (37:48):
I would say know that you know nothing and
that you'll change your mind allthe time, and that change is
cool and awesome and that you'llneed to ride unchanged.
Don't be so fixed.
Jonathan (38:06):
Well, if you could only wear one style of footwear,
what would it be?
Dr. Ellie Kazemi (38:09):
Oh, oh my God.
I wish I had prepared for thisquestion.
I can't even, I can't even thinkof what that would be.
It would be cool and weird withreally weird heels, but I can't
think of the name I like, I likethings that are retro.
Jonathan (38:26):
I love it.
Cool and weird with really weirdheels.
Boom.
There.
Well, Ellie, thank you so muchfor taking time to catch up and
for sharing your wisdom with ourfield.
I appreciate you.
Dr. Ellie Kazemi (38:38):
I appreciate you back.
Thank you.
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