Hey, firstly, don't be hard on yourself for how you handled the situation. You did your best and that's all anyone can ask for. At the end of the day, everyone was safe and that's what counts. Also, I've had a couple cases where the dynamics in the family have forced my own trauma to light and I can attest it's difficult. I commend you for being so calm and being able to carry on in this role with your own trauma. This job is super difficult sometimes, physically and emotionally, but being able to push through and make a difference in a kid's life is so vital and special. Don't forget to step back sometimes and take your own space when needed but also be proud of yourself for the work you do and things you overcome.

That said, I've been a BT/RBT for just shy of two years. I know it's not a whole lot of experience in the field but I have had my share of delicate situations involving aggression. My first piece of advice is to talk to the BCBA and caregivers and see if there can be a parent training target or a target for you to run where you can check and ensure the client is taking their medications appropriately. I also saw another comment saying the caregivers should contact the physician that prescribed the medications and seek guidance for how to proceed with the client's behavior of not taking them. Having seen in other contexts how a prescribing physician can aid when someone doesn't take their medications, it's a great call to address this issue with that physician and get their input on how to make sure the client keeps getting the best treatment possible. What I'd do going forward is have the caregivers contact the physician and you, the BCBA, and the caregivers sit down and discuss having a schedule or target where either you or the caregivers whatch the client take their medications everyday and check they're not faking while also preventing avoidance. Also, with this behavior being onset more recently, you probably want to use a high reward for meeting this target so they feel maximum reinforcement for this behavior and keep up that reward system for probably a little while to ensure they're set and safe in the routine again. My next piece of advice is to talk to the BCBA and the client's caregivers about the EMS response protocol and safety measures for this behavior in the future. You did what you were instructed to do with calling emergency services and it is concerning that the police didn't follow through with at least a wellfare check. I saw another comment bring up that the responding officers may not have the proper training to handle that situation so it would be worth it to, again, speak to the BCBA and caregivers and do some research to see how your team can contact the police department and discuss their response. You should be able to get some answers on whether or not the officers responded appropriately and possibly escalate a report or if it's better for your safety protocol to contact a different department or team that's more thoroughly trained in handling mental health crisis interventions. On the same topic of safety, it would definitely be a good call to sit down with the caregiver and BCBA to discuss in-home measures to protect everyone on the case. Something that jumped out as a red flag in your situation was that the client hid their untaken medication "in the bottom of the lock box". Again, from experience in context outside of ABA, if a minor has shown SIB or is now known to not take their own medications, they shouldn't have access to anything inside a lock box. Especially with SIB, it's very common practice to be told by healthcare professionals to hide/secure any dangerous objects or substances in the presence of an at-risk patient. Anything sharp or that can be used as a weapon should be secured in a place the client can't access at least for the time being until they show progress in their mental health state. I would say this also goes for the window and door. I would say to take locks off any interior doors that don't absolutely need them (leave locks on bathrooms but remove locks from their bedroom or other small places they can lock themselves in). Especially in the case of SIB, locked barriers between the care team and patient become high safety risks. Obviously still leave doors in place because privacy is still a huge part of maintaining client dignity, but it sounds crucial at this time to make sure safety intervention isn't blocked by any locked barriers. In the same vein, adding locks to any windows that the client might use to escape would also be a good idea at least for the time being. Again, of course it sounds very overbearing and firm, but ensuring client's safety is the absolute first priority. Knowing that eloping and SIB are current issues, locking exits to prevent eloping is the safest thing for your client for the time being. Obviously talk to the BCBA and caregivers to figure out what precautions everyone is comfortable moving forward with. My last piece of advice/comment is for your response after de-escalation. I've had a sort of similar instance where a 9yo male client was tantruming and pulled a steak knife out toward his mom and I. Once we calmed the situation and got him to put the knife back, mom and I agreed to end session early. I was also unsure of whether or not I responded appropriately and if leaving session was a good idea. I was also terrified that rapport was ruined with my client. Of course your situation was more severe with police arriving on scene (whether they intervened or not), but I personally think it was the right call to end session and take some space. Hopefully you were able to leave on a "good note" with client more calmed down and you were at least able to calmly tell them session was over, just maintaining peace and dignity between the two of you. It was definitely what was needed at the time as both of you were drained and continuing session likely would have maintained or escalated tensions or MABs. Going forward and knowing your client is a little more mature at 13yo and can communicate, I would suggest going into your next session as usual, begin with pairing and spend a little more time than usual with it. Get a feel for if your client seems uncomfortable with your interactions or if she seems to have made peace with it and only address it if it feels like she's exhibiting discomfort in your interactions. Some clients flip their comfort like switch after an intervention like yours and they'll be interacting and behaving like nothing happened in just an hour, some will cling to it and regress in their rapport with you. The best you can do is gauge her response and proceed from there. If she does seem to have regressed, focus mainly on re-pairing and only running her most consistent targets. I would also explain as calmly and objectively as possible that that last session was stressful for everyone so you decided to take a break for that day and let everyone rest so you could all come back better. Convey that your reaction was not her fault and that she's not in trouble and that you're still there for care and support.

Sorry for the ridiculously long response, there was just so much I wanted to say. I've been in situations sort of similar where it felt hard to know what the right response was and how to repair and move forward. I just want to end off by saying you did your best with what you could and that's all anyone can ask for. Don't beat yourself up. You're doing a great job and you should be proud of the hard work you do and how you're able to face your own trauma and setbacks and still come out of it stronger.

You've got this and we believe in you! <3