Beyond the Paycheck

Beyond the Paycheck

If I had several places to choose from, what would make me choose this one?

This is the question I’ve been carrying with me over the past few weeks. It is not exactly a question about which job offer to accept. It is a little more uncomfortable than that: How do we choose where to work when the conditions a company offers can be excellent, but we still don’t know whether that organization’s values align with our own? And this is not a new question for me.

A conversation that started in Brazil

When I was still working as an occupational therapist in Brazil, the debate surrounding ABA therapy clinics was already part of my professional life.

Sometimes, I felt frustrated seeing children receive services in clinics whose approach did not align with what I believed good practice should look like. Other times, I saw professionals choosing to work for certain companies because they offered better financial conditions, and I completely understood that choice. There was also the long-standing discussion about how many hours of therapy a child should receive each week and what happens to a child’s occupational balance when intervention begins to take up a significant portion of their life.

As an occupational therapist, one of the things that always stayed with me was the question of balance between intervention and life. A child is not just a child who needs therapy. They also play. They sleep. They eat. They go to school. They spend time with their families. They have friends. They have hobbies. They get bored. They rest. They develop interests. Those things are occupations, too. That is why I have always felt a tension between providing enough access to intervention and the possibility of turning a child’s entire life into a therapy schedule.

I already had these questions when I was living and working in Brazil. But now I am experiencing this conversation from a completely different position.

And then I moved to the United States

Today, I am not only a professional in the field. I am also someone looking for a job. And that changes the perspective completely.

I am no longer simply looking at a clinic and asking: “Do I agree with the way they practice?” Now I also have to ask: “Would I work here?” And suddenly, very practical things become part of the equation: salary, benefits, stability, supervision, professional development, training, career opportunities, and growth.

And I don't think there is anything wrong with that. Healthcare professionals deserve to be valued. We need fair salaries. We need good benefits. We need quality supervision. We need supportive work environments. We need opportunities to grow. The problem begins when we assume that these things, by themselves, are evidence of clinical quality.

The system is much more complicated than I expected

One of the things that has surprised me the most since moving to the United States is how fragmented access to services can be.

A family’s experience can depend on the state they live in, the insurance they have, the programs they qualify for, the availability of professionals, the school their child attends, and even whether they can obtain a diagnostic evaluation in a reasonable amount of time. Some children and families are able to access services relatively easily. Others face waiting lists, coverage limitations, provider shortages, or a fragmented system in which different parts of a child’s life do not always communicate with one another.

And when I think about this as a professional, I realize that good intervention depends on more than simply having a clinic available. It depends on how all of these systems work together.

And then came the large corporations

One thing that has really caught my attention is how quickly some healthcare and ABA organizations are able to grow. New locations. New hires. New opportunities. Career paths. Benefits. Competitive salaries. Training programs. Larger and larger organizational structures.

And again: this is not necessarily a bad thing. In fact, there are real advantages to an organization having the resources to provide better conditions for its professionals. But I started asking myself some questions.

Does a larger company necessarily provide better care? Does growth equal quality? Does offering an excellent career path necessarily mean that an organization will retain the best professionals? And even if it does retain excellent professionals, does that necessarily mean those professionals will have the autonomy to provide the best possible care?

Values Should Not Depend on Your Job Title

As I search for my next workplace, a few things have started to matter more to me. And I think it is important to explain why I care about these questions even when I am applying for something as seemingly straightforward as an RBT position. Because I don't think these questions should only matter to people applying for a practicum placement, a BCaBA position, or a BCBA role.

They should matter to RBTs and behavior technicians, too. An RBT may not be responsible for designing treatment plans, making clinical decisions, or supervising other professionals. But RBTs are often the people implementing interventions directly with children and families, day after day.

That means the organization's clinical culture is not something happening somewhere above them. It becomes part of their daily practice. How does the company talk about children? How does it respond when a professional has a concern? How involved are families? How does supervision work? What happens when an intervention does not seem to be working? How are disagreements handled? What does the organization prioritize when clinical needs and business needs do not perfectly align?

These questions can directly affect what an RBT experiences in their everyday work. And yet, I sometimes wonder whether we have normalized the idea that an entry-level professional should walk into an interview thinking primarily about hourly pay, available hours, and whether the company is hiring.

Of course those things matter. But they cannot be the whole conversation. I actually think companies should want to ask candidates these questions. If an organization is confident in its clinical culture, its supervision, its approach to families, and the way it supports its employees, why wouldn't it want prospective employees to understand those things before accepting a position?

And there is another reason I think this matters: retention.

We talk a lot about how to retain RBTs. Higher salaries. Sign-on bonuses. Benefits. Career paths. More training. And all of those things can help. But what happens when compensation and schedule are the primary reasons someone chooses a position? If another company offers a higher hourly rate, more consistent hours, or a schedule that fits their life better, what is keeping that person from leaving?

And this is where I think values and clinical alignment matter. If an RBT does not feel connected to the organization’s approach to care, does not identify with its values, or does not feel invested in the children’s development and the work they are doing, then a better offer somewhere else can become a very easy reason to leave.

They move to the next company. Then another company offers a little more. And the cycle starts again. That does not necessarily mean the RBT is uncommitted or unprofessional. It may simply mean that the organization never gave them enough reasons to stay beyond compensation and schedule.

If the only things keeping someone in a job are the paycheck and the schedule, then retention becomes a bidding war. Maybe one of the most overlooked aspects of retention is not simply paying people more, but helping them find a workplace where they feel that the work itself is worth staying for.

Maybe one of the most overlooked aspects of retention is hiring for alignment in the first place. Not hiring people who think exactly the same way, or creating teams without disagreement, but making sure that the people joining an organization understand its clinical philosophy, expectations, culture, and priorities, and have the opportunity to decide whether those values align with their own. And if the right alignment is not there, perhaps the better choice is to grow more slowly rather than expand indiscriminately, hiring anyone who happens to be available simply to keep up with demand.

That is why I believe these questions belong in every level of the hiring conversation. Not only when a BCBA is interviewing for a clinical leadership position. Not only when a BCBA student is looking for a practicum. Not only when someone is applying for a supervisory role. Even when you are applying for your first RBT position. You are not just interviewing for a paycheck. You are interviewing for the place where you will learn how to practice. And the company is not just interviewing you. You are interviewing them, too.

So, as I search for my next workplace, these are some of the things I am trying to pay attention to:

1. Listen to how the organization talks about children.
Does it talk mostly about diagnoses, behaviors, and productivity? Or does it also talk about interests, autonomy, family, participation, and quality of life?

2. Ask how clinical decisions are made.
Who makes them? The BCBA? The team? The family? Is collaboration actually part of the process?

3. Ask how the organization handles disagreement.
A healthy team should not be one where everyone always agrees. It should be one where professionals can ask questions without fear.

4. Ask how quality is measured.
The number of clients and billable hours may matter to a business. But they should not be the only measures of clinical success.

5. Pay attention to how professionals are described.
Are they simply employees who need to fill schedules? Or are they professionals who need support, development, mentorship, and autonomy?

6. Ask about the family.
How much is the family involved? How are caregivers trained? How are their priorities considered?

7. Think beyond the clinic.
Does intervention prepare a child only to function better within that particular environment, or does it help build skills that actually matter in the child's life?

Maybe I still don't know where I want to work And that's okay. Maybe this is one of the things I am learning through this career and country transition. In Brazil, I had a relatively clear idea of the kind of professional practice I wanted to build. In the United States, I am having to rebuild that idea within a system I am still learning to understand. And maybe choosing my next job is also an opportunity to discover which principles are truly non-negotiable for me. Because, in the end, I don't just want to find a company that will give me a job.

I want to find a place where the professional I want to become can exist. And maybe this is a question all of us in healthcare should ask ourselves from time to time: If I had several places to choose from, what would make me choose this one? Not just the salary. Not just the benefits. Not just the title. But the values.

Because when our work is about caring for other people, where we choose to work is more than a career decision. It is a reflection of the values we choose to stand behind, the professional we choose to become, and ultimately, the kind of care we choose to provide

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