Timothy Zercher 0:00

Well, Nicole, thank you so much for joining us. We really appreciate you taking time.

Dr. Nicolle Carr 0:03

Thanks for having me.

Timothy Zercher 0:04

Absolutely, absolutely. I'm super excited to learn a little bit about you. So I want to just jump right in. What first drew you into behavior analysis and what has kept you so deeply committed, especially to the ethical practice in this field?

Dr. Nicolle Carr 0:18

It's crazy. I think there's kind of two groups of people who find their way here. There's the Mies, the whoops, look what I found myself in, accidental, whether it's as an RBT, they just saw an ad at a Starbucks on a billboard, or they just needed a job. Or in my case, I finished a PhD program and wanted to live in a cool city. And so I applied for all of the jobs that my PhD fit the piece for. And it was in behavioral neuroscience. So it wasn't, this was not the plan. And but Boston had some cool jobs. And so I applied for a variety of jobs there, statistician at Harvard and a clinician at a residential facility. And after going on all the interviews, I decided the basement of Harvard was not the place for me. So I ended up at a residential facility. And I'd worked like special, like the special Olympic softball team and stuff in high school, but had never worked in any capacity with those who had special needs. And so, but the guy who ran the residential believed that conditioning is conditioning and the science is the science. And so most of my PhD work was in Pablovian conditioning and sperm output of quail, super random. But it was like, exactly. That's the face I usually get. But it's it was the science, right? And so I got hired and then boom, I'm working with humans. And then Boston, the state of Massachusetts, actually said if you work with folks who have special needs, you have to become a BCBA. And this was in 2007. None of us knew what the heck that was. So we looked it up. Penn State had a program and boom, I am here in the field. And then I think the other group of people have some direct connection. They have a brother, a sister, a niece, a nephew, a neighbor who has autism. And so they kind of get into the field that way. And I don't think any of us are more committed or less committed or more passionate or less passionate, but there's definitely seems to be these two groups. And I'm totally in the accidental group.

Timothy Zercher 2:21

It makes sense. It makes sense. I think the accidental group sometimes bring the most diverse perspectives to the field anyway.

Dr. Nicolle Carr 2:29

Yeah. I think each of us come at it from a different passion for it, but at the end of the day, it needs all of us to make it work. So I'm happy to be here for sure.

Timothy Zercher 2:39

Absolutely. So a lot of your work centers around ethics and access. Where do you think the ABA field still struggles most when it comes to translating good intentions, good ideas into actual good practice?

Dr. Nicolle Carr 2:55

Ooh, that's a whole bag of worms. I think two spaces. One is rural, and that's one of the things that I'm in Oklahoma. Most of it is rural, right? We have the, I call it the ABA corridor, which is Tulsa to Norman or Oklahoma City, if you will. It's along an I-35 highway, and then it goes the Turnpike to turn to Tulsa. And about 80% of our ABA clinics are right there. And after that, you have one over here, one over. I can tell you on a map where these other seven clinics are at, right? In the whole state. And so you have parents who are having to drive one to two hours one direction to get treatment. And it might not even be the best treatment, but it's the only treatment. And so there's people ask me all the time about telehealth. How do you feel about it? And I said, if you lived in Oklahoma, you would understand there's a time and a place. Because the other option is zero treatment in a lot of spaces to get BCBAs to move to the middle of nowhere is difficult if they're not already from there and passionate about it. And so telehealth kind of fills that spot until they're able to home grow a BCBA through an intern pipeline or something. And so for me, rural access, super important. And then the other pillar, I guess, that I have no leg to stand on because this is not changing anytime soon in Oklahoma, anyways, is what about everybody who doesn't have autism who still needs treatment? Here, insurance only provides for those who have autism. Most schools at the higher education level work really hard, like as it relates to autism. And all that's great. But coming from the residential where it wasn't autism specific, it works really well across the board. And so it's hard in many ways to realize that it's just for this sub-population of folks. At the same time, I also see the cost of it. So how are you going to open it up to everyone who has a behavioral need? However, I think that it could be so use in schools, like at least schools are somewhat getting it right. They have BCBAs and I used to consult in schools. I did the high behavior kids, not the autism kids. My friend did that group. And so at least a school who isn't beholden to insurance requirements is starting to figure that out. But for the rest of who has access, I think that there's a large group of people who don't have access because they don't have the right diagnosis.

Timothy Zercher 5:22

Absolutely. Absolutely. Or not even the right diagnosis, the lucky diagnosis that allow them to have ADA.

Dr. Nicolle Carr 5:29

Yeah. And what you've been seeing in the clinics are kids who walk in and you're like, I don't really think this kid has autism. But you know that there was a medical doctor or a psych somewhere that was like, but they really need the service and I can kind of get there, you know. And so you're like, you know, all right, here we are.

Timothy Zercher 5:46

Call it autism so they can actually get with it.

Dr. Nicolle Carr 5:48

Yeah, yeah, exactly. Like diagnosing them with anxiety so they can get the certain set of meds, even because like how all the how everything works in insurance, right? You got to check the right box to get the right treatment.

Timothy Zercher 5:58

So yeah, unfortunately, a lot of doing good work includes dealing with insurance.

unknown 6:04

Yeah.

Dr. Nicolle Carr 6:04

Working within the parameters, yes.

Timothy Zercher 6:07

Exactly. So you've worked across academia, consulting, leadership, and even public speaking. What have you learned about helping clinicians make better decisions, especially in the real world when things are not as clear-cut and direct as they are in a textbook?

Dr. Nicolle Carr 6:23

They are not. To the point that I wrote a book all about those gray areas, right? Because they're that's actually where most people live. And I used to teach, well, I mean, I still teach, but I teach ethics often. And at the I would use Bailey and Birch's text, the text, right? Everybody uses Bailey and Birch's text. And it's great. And John Bailey is great. I love, you know, and Hanley is like all the people that have written the books, Broadhead, all these folks who've written the books on ethics, they're great. But what I was finding is I was graduating students who thought that what they were gonna come into a situation where the biggest issue was I given an $11 gift card, which I can't take because the rule is $10. Or am I going to see somebody writing about a student that was never there? Fraudulent billing, obvious. But the real world is that I had a parent once that came in and it was either like, I find a way to put this kid on my caseload, or she was putting the kid in foster care. Do you expand your caseload to more than you really should? You know, you can't give everything to every client on that caseload, right? Or you tell the mom, Aunt, sorry, honey, go put your kid on a in foster care. And those are the real world issues that actually pop up on a daily basis. A kid comes in and they're scratching, a sibling has lice. Do you assume they have lice and send them home too? That's not in our ethics code, but these are the real world decisions that we make on an everyday basis that matter. And you have these really hard conversations and you teach, and you're like, this is the code, and 5.2 and 10.4, and all the things, and they memorize it, but then they still have no idea what they're doing when they get into the real world. And so giving them just real life application, real life scenarios, one after another after another, I think is the important part of teaching and also making it the norm to talk about that. See something, say something, right? comes up often here at our clinic. We're always talking about the scenarios because I don't want anyone to ever feel like they can't bring it up. You bringing something up doesn't make you this big bad whistleblower. It's you seeing something so that we can make changes and get you the best information or help you make a better decision. Because we have some folks who have been like, I've been doing this since 08. There's another lady that's been doing it since 10, another one who's about five years in, and then we have three in the last year. And so I don't want them necessarily making decisions in some cases without us. And if you make them feel bad about bringing you situations, then they're not gonna bring them to you, right? And so you have to keep this open line of communication. You have to reinforce them whenever they bring stuff to you so you can work through it together, explain why you came to that decision. And sometimes the idea of an ethical dilemma isn't a right versus wrong. Usually it's a kind of right versus a kind of right, but both of them have some crap to them that comes along for the ride. And so wading through what the best option is, given that neither of these are super perfect options. And that's hard also for people to realize that there's it's not gonna be like, yes, that was the best decision ever. There's gonna be a sad mom, or there's gonna be an overextended caseload, or there's gonna be X, Y, and Z.

Timothy Zercher 9:41

Absolutely, absolutely, which makes complete sense. And I think we would all do better if textbooks and classes caught more in the gray of reality than they did in the clean black and white simplicity that's yeah, more realistic scenarios, yeah. Exactly, exactly. I mean, I think that's the case in almost every profession that there is, right? Isn't cool. Textbook says this or this, it's somewhere in the middle. Where do I do that?

Dr. Nicolle Carr 10:02

Right here, yeah. I always teach people, and I wanted to call the book, but the publishers were like, nobody will search for that, but it depends. Because if somebody comes to you with an issue, right, like your first response when they're like, is that ethical? I always feel like your first response should be it depends. Unless dear God, I just saw an RBT hit a kid in the face. Okay, that's not an it depends situation. Right. That's one of those right versus wrong. But for most parts, should we do this or this? What happens? Did it? Well, it depends. Tell me more. Like you've got to go on this fact-finding mission to have as much, and you're never gonna have all the details. That's the other part of it. You're never gonna have all the details. So you get as many as you can and you make the best decision you can. And you can use Broadhead's decision model, you can use the BACB's decision model, whoever's you're the most comfortable with, but the end, you're still like, uh, based on what I know currently, what should I decide?

Timothy Zercher 10:51

So yeah, no, it makes complete sense. Since we are a marketing agency, we always have to ask some more marketing type questions. First up is what works best for you right now outside of word of mouth when it comes to client acquisition?

Dr. Nicolle Carr 11:04

This is you're it's being that you're in marketing, you're gonna hate my answer because it is. I'm doing a very grassroots strategy. We have a website, obviously, and we have Facebook and Instagram and LinkedIn, of course. But once we get those referrals, then through that, like we're just a parent just clicked, they want more information. The best set of clients that I've got lately is whenever I took on this role about six months ago, I went back to all of the clients for the last five years and I texted every parent and was like, hey, I hope you found the services you were looking for. But if you didn't, or you just need a resource about autism, love to be that person. Let me know if I can be helpful. And obviously, in five years, most of these folks have developed relationships with their current ABA companies, or they don't want it or need it anymore. And all of that is great. But there was quite a few parents who were like, actually, I do have a question about IEPs or autism or OT. How does that fit in there and all the things? And I firmly believe that being a resource for the community is one of the best ways to, even if it's two years later, somebody's there's this girl I know, you can call her. She works at a company and it's somebody's cousin's brother's little sister that has a kid. We've received around 10 clients. And for us, that's really good. That's we're a very small company. And so over the last couple of months, we've onboarded about 10 different clients just through this backward campaign. I don't even know what it's called, but this super grassroots, me texting people, talking to parents, answering questions that have nothing to do with us, but just a resource about autism because it's drinking from a fire hydrant, right? You get that diagnosis and it's just like, and you don't know who to trust. You Google it and 50 million hits. So, like, how do you find somebody you trust the answer for?

Timothy Zercher 12:56

Absolutely. No, I I don't hate that at all. In fact, I think it's very I mean, in marketing, we would call it network activation. So activating your existing network, the people that know you.

Dr. Nicolle Carr 13:05

Let me write that word down. Network activation. Got it.

Timothy Zercher 13:09

Or sometimes we'll call it a graveyard campaign, which sounds a little bit less cool, I guess.

Dr. Nicolle Carr 13:14

Uh no, I think I like that one better. Yeah.

Timothy Zercher 13:16

Yeah, but it sticks in your mind because it is. It's going back to the people that are no longer a profitable relationship, but trust you already and know what you're all about. They're the best place to start almost always. Especially if you're allowed, like a lot of groups that have NDAs in in in place and things like that they can't contact. But if you can talk to your old clients, that is by far the best. So good on you. I think that's I think it's a very good marketing decision. Well, thanks. Absolutely. And the last marketing question then is what is one tactic that you're either considering or just watching really carefully in the marketplace right now when it comes to either client acquisition or talent acquisition.

Dr. Nicolle Carr 13:53

I think it'd be remiss if I didn't answer AI, right? That's all the things. And that's trying to infiltrate ABA in all the capacities from notewriting to scheduling to like social media to how Indeed works and all the different ways. And so we're still working really hard to have people doing that. We're so small that right now we can. I'm sure there might be get a point where it's we don't have the infrastructure to do all the pieces we want. And it would be nice to offload it to pieces of it to AI. I mean, trust me and Claude, we're like this. So it's not like I think AI is terrible. So, however, when I read a LinkedIn ad for a job or I CEO friends, and I'm like, just write it yourself. What are you doing? Because it's so AI'd. There's a rhythm, right? When AI writes it, you can read it, everyone knows it. And for me, it's a turnoff. And so whenever I was job hunting seven or eight months ago, I did not respond to those. Because for me, I wanted somebody to put their passion into what they were offering to folks. And I feel the same way. So I ask our HR lady to please maybe AI can tweak it a little bit, but go back in there and make it us. Make it, we're very grassroots, we're very people-to-people relationships. And so I don't want it to look like a computer wrote it.

Timothy Zercher 15:12

I think that's it. That is the way to do it. I think that people that overuse AI, it's visible to everyone and it hurts them in a lot of ways. So that makes complete sense. Well, thank you so much. We really appreciate you coming on. We appreciate you sharing your experience and your kind of your breadth of experience because you've had so many roles in so many places. So thank you so much. We really appreciate it.

Dr. Nicolle Carr 15:32

Yeah, thank you so much. It's great to be here. Yeah.