Key Takeaways
- The field-level problem is real and measurable. Applied behavior analysis has been criticized for treatment delivery that lacks compassion, even as clinical outcomes hold up. Nohelty and colleagues at the Center for Autism and Related Disorders responded with a 2024 Behavior Analysis in Practice pilot that built a Compassionate Care Measure from scratch and trained nine clinical supervisors over five weeks.
- Research methodology does not survive the move to production. Video-recording every supervisor session and scoring it one-on-one was feasible in an IRB study with nine participants. At a multi-state provider, it is neither feasible nor necessary. Nohelty’s team replaced it with group-based behavior skills training, structured worksheets, and embedded checklist items.
- The mechanism of change is checklists, not the measure itself. 360 Behavioral Health does not run the Compassionate Care Measure on its workforce. Instead, compassionate care components, such as aligning with caregiver priorities, using understandable language, and exploring caregiver culture, sit inside existing supervisor procedural fidelity checklists (PFCs) in the company’s data platform.
- Compassion is becoming a system, not an initiative. Nohelty’s next research project flips the original sequence: assent-based care, an emerging standard for client-level compassion, is being studied empirically after the manualized training has already been built and deployed. The implication for other providers is that compassion is a culture problem first, a measurement problem second.
Karen Nohelty’s 2024 pilot operationalized compassion as a measurable clinician skill. Two years in, the implementation looks nothing like the study, and that, she says, is the point.
Karen Nohelty has spent the past several years on a translation problem. The first half is well-documented: in March 2024, she and four co-authors, including 360 Behavioral Health Chief Clinical Officer Dennis Dixon, published a pilot study in Behavior Analysis in Practice testing whether a five-week training package could measurably improve how board-certified behavior analysts engage with the parents of their autistic clients. Nine clinical supervisors participated. The intervention combined didactic instruction, behavior skills training, and acceptance and commitment training. The team built a new measurement instrument, the Compassionate Care Measure, specifically for the study. Results were modest but encouraging: clinicians improved, the variability in their scores across different caregivers narrowed, and the largest gains came from supervisors who started with the lowest ratings.
The second half of the problem is what to do with that finding inside a working ABA company. Nohelty, now Director of Research and Development at 360 Behavioral Health, has been quietly running that experiment ever since.
“Research and clinical practice are different,” she said in an interview with Acuity Media Network. “There is a gap in terms of translation from research to clinical practice. Some of the things we did in the study are not things you would necessarily want to do in clinical practice, or can do.”
That gap matters for anyone trying to operationalize compassion as a competency rather than a values statement, and the question has acquired commercial weight. With BCBA demand outpacing supply by roughly 50,000 positions and the workforce skewing junior, providers are under pressure to differentiate on quality and to retain the clinicians they have. The BACB’s 2026 workforce data make clear that the field is scaling faster than its supervision infrastructure can keep up with. How a national provider trains its supervisors to manage difficult conversations with caregivers is no longer a soft-skills question. It is a retention question, a clinical-outcomes question, and increasingly a payer-relations question.
From a Pilot Measure to a Working System
The 2024 study, with all of the research conducted at the Center for Autism and Related Disorders before Nohelty and Dixon completed the manuscript at 360 Behavioral Health, was designed to do something the field had not yet done: take a broad inventory of what compassionate care actually looks like in caregiver interactions and turn that inventory into observable, measurable behaviors. Nohelty’s team conducted a comprehensive literature search across ABA and the broader medical field on soft skills and compassionate care, drafted a list of competencies, wrote behavioral anchors for what good and not-good versions of each skill looked like, and ran the list past outside experts.
The resulting Compassionate Care Measure was organized into two levels. Level one captured foundational skills that apply to nearly every caregiver interaction: active listening, building rapport, using understandable language. Level two captured the harder, more individualized work of responding to caregiver stress, navigating conflict, and acknowledging cultural context.
Other instruments have since emerged in the same space. The Compassionate Collaboration Tool, developed by Jessica Rohrer, Kimberly Marshall, Colleen Suzio, and Mary Jane Weiss and published in 2021, takes a narrower scope, focusing on a defined set of skills in three categories: basic interview behaviors, interest-related skills, and joining with the family. Nancy Marchese and colleagues subsequently developed the Parent Partnership Questionnaire, published in 2023, which assesses the caregiver’s perception of the clinical relationship rather than scoring the clinician directly.
“I think there’s a lot of benefit to both approaches, both the broad approach that we went for and the narrow approach,” Nohelty said. “You have these very narrow kind of scoped competencies. And ours is broad. They serve different purposes.”
What Got Dropped, What Got Kept
The translation from study protocol to clinical practice required deliberate subtraction. The original pilot used one-on-one behavior skills training, with a single trainer working through the four-step instructional sequence with a single trainee. It also relied on video recordings of supervisor sessions, scored against the Compassionate Care Measure as the primary outcome.
Neither survived the move to production. “In the study we took videos of each BCBA and scored those videos. That is just not feasible,” Nohelty said. “It’s not even necessary to get high-quality services, which is really what we’re looking for in clinical practice.” That level of measurement was a requirement of the research design, where controlling conditions is what gives investigators confidence about what is driving an outcome. In a working clinic, the calculus shifts toward balancing feasibility against scientific certainty.
The training itself was redesigned around group delivery. The four steps of behavior skills training, instruction, modeling, rehearsal, and feedback, were preserved, but rehearsal and feedback moved to a worksheet format. Supervisors select a real caregiver from their caseload, work through a structured worksheet that walks them through applying a compassionate care concept to that specific relationship, and submit the worksheet for review. Nohelty provides feedback on the completed worksheet rather than scoring a video. In some respects, this is an improvement on the original pilot. Because supervisors work with a real caregiver on their own caseload rather than an abstract scenario, the exercise feeds directly into better care for that family.
The measurement layer migrated, too. 360 Behavioral Health is not running the Compassionate Care Measure on its supervisor workforce. Instead, the company’s data collection platform, Hi Rasmus, houses a battery of procedural fidelity checklists used to rate supervisors on specific tasks, such as conducting in-home parent training. Compassionate care components were woven into those existing checklists rather than added as a parallel scoring layer.
“Example components include aligning with that caregiver’s priorities, using understandable language, exploring the caregiver’s culture, and building trust with them,” Nohelty said. “We’ve found that the best way to add in a competency check component is by building compassionate care elements into the existing checklists that we’re using.”
The economic logic of that choice is straightforward. A pilot measure inside an IRB study can ask supervisors to spend hours being video-recorded and scored. A working production environment cannot ask supervisors carrying caseloads to do the same, particularly when waitlists are long and clinicians are scarce. Building competency checks into instruments that supervisors and managers are already using means the operational cost approaches zero.
Nohelty argues that she believes there is a downstream clinical benefit. “If clinicians are more compassionate up front, if they show up that way with caregivers, you’re avoiding conflict,” she said. “I hypothesize that if you limit cancellations, you are able to get more caregiver meetings and fulfill your authorized number of parent training hours. We don’t have research on that, but that’s what I hypothesize.”
Compassion as a Culture, Not a Checkbox
The broader bet at 360 Behavioral Health is that compassionate care cannot be siloed as a discrete training intervention. Nohelty led the development of the company’s Clinician Handbook, which includes a dedicated chapter on compassionate care and weaves the construct through every other chapter. Monthly continuing education sessions for supervisors return to the theme. A new supervisor onboarding curriculum carries it through as well.
“What we want is a culture where all of our clinicians, all of our leaders, are engaging compassionately with caregivers and clients,” Nohelty said. “Making culture change, especially at a larger organization, is something that takes time and takes focus and takes everyone being on the same page.”
There is also an ethics overlay. The Behavior Analyst Certification Board’s 2022 ethics code names compassion as a core principle and includes specific requirements that map onto the construct, such as using understandable language with caregivers and stakeholders, engaging in cultural responsiveness, and obtaining client assent where applicable. For BCBAs, behaving compassionately is not optional. The training infrastructure is what allows them to do it consistently.
Nohelty’s next research project illustrates how the relationship between research and practice can run in either direction. Assent-based care, which extends the logic of caregiver-directed compassion to the client and asks how clinicians can support a client’s moment-to-moment willingness to participate in treatment, has been an active area of clinical development at 360 for several years. A manualized training already exists. Now Nohelty is taking it back into the lab.
“With compassionate care with caregivers, we did the research study and then we translated to clinical practice,” she said. “With assent-based care for the past number of years, we’ve developed trainings and we basically at this point have a manualized intervention for how to support that. And now I’m translating it into a research study. Sometimes things go the opposite way.”
For other providers considering a similar build, Nohelty’s advice is to start small. “The minimal viable product is anything better than what you’re doing now,” she said. The 2024 paper, she notes, can serve as a baseline assessment tool. Pick a single competency, work on it, and only then move to the next. Most importantly, run the training in groups, not one-on-one. The one-on-one approach was a research-design choice, not a clinical recommendation.
What she would not have a midsize provider replicate is the impulse to bolt the Compassionate Care Measure onto an existing supervision system as a standalone scoring instrument. The mechanism of change in production, she has come to believe, is integration.
“At 360, everything we do comes from this compassionate care lens and approach. More than just measurement, more than just checking off boxes on a CCM or another tool, having it be this shared value that’s woven into everything is something that can really make the biggest difference for our families and our clients.”
