Autistic ABA Practitioners – The Canary in the Coal Mine

[I]t was a traumatic experience as an RBT and can’t imagine how these kids feel getting the “treatment”. I will never forget my time there and how I was treated. It will stay with me forever.

Nancy Cervara, autistic ex-RBT

This experience reflected my own. I will forever be impacted by how working in Applied Behavioral Analysis (ABA) traumatized me, and I was troubled to hear that I was not alone.

Something that is very rarely explored in the ABA discussion is the clinician’s experience with it. I am unaware of a source that has examined autistic ABA practitioners’ perspectives.

I was pleasantly surprised at the outpouring of support from autistic ABA clinicians and ex-clinicians that wanted to share their perspectives. There has been a valuable voice missing from a nuanced dialogue.

“New ABA” is at the heart of contention, with parents and providers swearing it’s changed so fundamentally that it is now ethical and safe. ABA survivors and autistic people have warned that it is the same therapy with a new coat of paint.

One of the significant problems in this conflict is that most survivors of ABA abuse experienced what has been cleverly categorized as “old ABA.” Often, their experiences are dismissed by parents and ABA providers alike because they didn’t go through this “new ABA.”

One group of autistic adults has an inside look at exactly what the “new ABA” is all about.

Autistic ABA practitioners. One of the most hated groups in all of ABA. They are patronized and subjected to ableist situations daily by their peers and rejected and despised by their own community. And yet, they are one of the most valuable resources in reflecting the current state of ABA.

A common critique of ABA is that there aren’t enough autistic individuals represented in leadership and research.

Why is that?

I obtained interviews from six current or former ABA practitioners that provide valuable insight into barriers autistic people face in the field and changes that need to be made.

Who Was Interviewed?

Current Practicioners5/6
Practiced Discrete Trial Training (DTT)6/6
Practiced Naturalistic Teaching (NET)5/6
Worked in “All” Settings (Clinic, School, Home)3/6
Diagnosed After Working in ABA5/6
Has/Had BCBA Credentials4/6
Interview Demographics

Barriers Placed by Neurotypical ABA Peers

Weaponizing Professionalism

“I told the HR director that that supervisor was in violation of the ADA and that individual’s rights…I pointed out that if the organization claimed to be trauma-informed then they needed to be trauma-informed for both their learner and their employees. The HR director was not happy with me, and later on, before I left, there were attempts to entrap me with write-ups for things that had been resolved months before, which I resolved as soon as they were brought to my attention.” – Brian Middleton, BCBA

“I opened my mouth about how I did not like the things we did. Someone told on me and I was harassed for two weeks and they lied about me leaving kids in dirty diapers and other things. They eventually had forced me to quit and told me that if I ever want to come back to the company, that write up will follow me.” – Nancy Cervera, ex-RBT

“I would like to be quoted anonymously…Too many good people in the field have had their credentials questioned. Sad that I have to fear for my credentials but I do.” – Anonymous BCBA of Divergence and Dissonance

“The director of one of the companies I worked at is the president of our state licensing board and I am concerned I could face repercussions for speaking out against her, as I know other people who already have.” – Anonymous BCBA 1

Anti-Autistic Sentiments

“I was definitely discriminated against for common characteristics of autism-my direct way of speaking, especially-and it was always a situation with an overly sensitive neurotypical person. I was always giving them the benefit of the doubt… but they never did the same for me when it came to how direct I am. They automatically assumed I meant the worst.” – S. Adams, BCBA

“Disclosures about my challenges have most often resulting in people trying to manage me so that my challenges impact them less. Usually in ways that are not only unhelpful, but also make my job harder.” – Anonymous BCBA 1

Woman holding head in hands, looking at computer screen with multiple notebooks. She looks frustrated.

Do you think ABA is a safe environment to work in as an autistic person?

“No, not in the slightest.” – Anonymous BCBA of Divergence and Dissonance

“Yes and no. It depends on whether the people in charge of the organization understand what autistics need or not.” – Brian Middleton, BCBA

“No, definitely not. I am autistic and knew it was terrible the moment I stepped in for my first day. I didn’t know I was autistic then, but realized it after.” – Nancy Cervera, ex-RBT

“No. Based on my experience, its an unequivocal no. I honestly believe that the stress and trauma I have experienced in this industry has contributed to me developing fibromyalgia.” – Anonymous BCBA 1

“As long as the environment is genuinely supportive and provides accommodations, it should be safe. Every clinic is not the same, but I can’t confidently say that most are genuinely safe spaces for autistic voices…If you’re a neurotypical person reading this, you can make ABA a safe place for us to work by first listening to our voices. It’s possible.” – Tee (she/her), RBT

Reactions of the Autistic Community

“I’ve received death threats. I’ve been called racial slurs, and I’ve been called an abuser.” – Tee (she/her), RBT

“I have received a lot of hate. It hurts, but I understand why. I have been told that I am a token. I have been compared to someone who has been through conversion therapy. I have seen the ban lists where my name was next to some other people with whom I completely disagree. I have received hateful messages, including some threats… I have learned that my best course of action is to keep teaching and modeling how to be a humanistic behavior analyst.” – Brian Middleton, BCBA

What Needs to Change?

Woman holding a microphone and talking into it pointed directly at a man

Better Education

“More well-rounded educational requirements for clinicians, higher standards and better training for RBTs, required learning directly from autistic people in some format.” – Anonymous BCBA of Divergence and Dissonance

“First, inclusion on extensive training on autism & neurodiversity awareness, acceptance, and inclusion training in all ABA programs, and a requirement that all BCBAs that serve such populations received that training as well… Second, there needs to be extensive training on how the commonly accepted and used techniques used in behavior analysis can and do cause harm. This includes training and demonstrating how assent-based interventions work in a contrast to compliance training.” – Brian Middleton, BCBA

“I firmly believe that extensive knowledge of childhood development and psychology should be required to work in this field of work. When you understand and acknowledge these subjects, you will understand why specific ABA techniques and expectations are problematic.” – Tee (she/her), RBT

Focus on Self-Advocacy and Autonomy

“[G]reater focus on self advocacy and autonomy and less focus on “problem” behaviours that are generally symptomatic of a problematic environment and unmet needs.” – Anonymous BCBA of Divergence and Dissonance

“The goal should not be compliance; the goal should be cooperation. We should be working to improve the quality of life of the autistic individuals we serve.” – Tee (she/her), RBT

“[T]here needs to be an emphasis on self-management, autonomy, and generalization practices in behavior analysis. There is extensive research in ABA on these topics, yet there is not a lot of it being applied.” – Brian Middleton, BCBA

Better Success Measures

“I also think a way needs to be found to shift away from productivity and worth being measured in hours, an arbitrary social construct that is meaningless to large numbers of ND people.” – Anonymous BCBA 1

“[B]etter social validity measures involving the client rather than just the stakeholders.” Anonymous BCBA of Divergence and Dissonance

It Can’t Change

“I would eradicate ABA completely. The worst type of “therapy” there is.” – Nancy Cervera, ex-RBT

“I’m honestly in a place where I’m not sure if the field can be reformed…” – Anonymous BCBA 1

“[I]t is more than obvious to me that advocating against the oppression of Autistics (mainly children and those with high support needs in various life areas) within the field of ABA is toxic and detrimental to one’s mental and emotional health. ” – NT ex-practitioner*

* NT ex-practitioner wasn’t formally interviewed but I requested to use their quote as I felt it was a good summation of some of the other sentiments expressed here.

Silver Linings

“When I realized that this field of work had caused so much damage and destruction, I had a major meltdown that caused a downward spiral for a few months. I didn’t think there was a way to practice ABA ethically, but there is. It’s not necessary to use intensive interventions; it’s not even essential to use punishments. We can change motivation from extrinsic to intrinsic. It’s hard work, but it’s possible and worth it.” – Tee (she/her), RBT

“I believe that ABA can be a humanistic approach to learning and teaching. I believe that there is a better way. I am committed to making it so that the dominant species of ABA is one where the autonomy and individuality of the individuals served are respected. I fully accept that I will be hated and reviled by people on both sides for my view, and I also hope that there will be meaningful change in this field sooner rather than later. In fact, I am already seeing it. That, more than anything else, tells me that ABA can be and is able to do and be better.” – Brian Middleton, BCBA

“I’ll likely choose to leave the field at some point, but at the moment I try to improve my own work and provide ethical and affirming supports. The work I am taking on allows me a great deal of freedom to do so.” – Anonymous BCBA of Divergence and Dissonance

“I guess I could walk away from all of this by recognizing that the rigidity and ableism in this industry is what exacerbated my struggles to the degree that I was actually able to recognize I had a disability. I was able to cope and mask effectively enough to get by until ABA made it abundantly clear that I was not enough and was not valued.” – Anonymous BCBA 1

Catatonia – More Than Just Freezing

My heart races as I freeze, my whole body flexed in an uncomfortable position. I cannot move or speak, and I am stuck staring ahead. This feels like sleep paralysis, but I’m awake?

It feels like I should be able to move. I command my legs and arms to move, but nothing happens. My brain is trying desperately to maintain this illusion of control.

Like sleep paralysis, I have the urge to scream, but nothing comes out. The more I fight, the worse I’m pulled into this sense of helplessness. It’s a waking nightmare.

I’m experiencing catatonia.

Over time, catatonia becomes another mental health symptom I greet with resigned familiarity.

At least 1 in 10 people with severe mental illness will experience catatonia at some point.

Despite this, information on catatonia is not widely available. I didn’t learn the name for my catatonia from any doctor or therapist. I had to actively search to find a name for what I was experiencing.

Who Experiences Catatonia?

Catatonia is a prominent feature in schizophrenia (up to 35% of people with schizophrenia). It is classified under psychotic disorders but “can occur in the context of several disorders, including neurodevelopmental, psychotic, bipolar, depressive disorders, and other medical conditions” (DSM-V, 2013).

Nearly one-third of people with bipolar have it, roughly 3-12% of autistic people have it (across multiple studies), one small sample found 87% of people with Tourette’s met the criteria, and in one sample of inpatients with catatonia, 57% had experienced childhood trauma (ACEs). Psycho-physiological symptoms, BPD, dissociative amnesia, and paranormal experiences may also be correlated with catatonia.

What is Catatonia?

While they are under the same definition in the DSM-V, catatonia is often split into two categories. There are two main types of catatonia, akinetic and excited.

Akinetic is the most common. It is characterized by at least three of the following symptoms:

  • immobility
  • mutism
  • withdrawal
  • refusal to eat
  • staring
  • echolalia
  • echopraxia
  • atypical inflexible postures (posturing)
  • resistance to movement
  • repetitive movements
  • declining requests or not responding for no apparent reason (negativism)
  • grimacing

Excited type may be characterized by any of the symptoms in akinetic type but is also characterized by agitated psychomotor behaviors, which may express as meaningless movements or vocalizations and may result in self-injury or aggression.

Considering the prevalence of catatonia in autism, there are significant implications with excited catatonia type. Self-harm and aggression may be expressions of catatonia in autistic people, which further raises ethical concerns for behavioral interventions if catatonia is not considered as a differential diagnosis.

In extreme cases, there may be malignant catatonia which can be lethal. This is generally descriptive of drastic physiological changes (like blood pressure and hyperthermia) in catatonic episodes or other complications like malnutrition from a prolonged inability to eat.

Catatonia exists on a continuum of severity ranging from minutes to weeks. Historically catatonia was only diagnosed if it was extreme, but now it is considered commonly associated with many mental and medical diagnoses.

Treatment for Catatonia

Treatment for catatonia typically uses electro-convulsive therapy (ECT) or benzodiazepines. In addition to these treatments, psychological therapy also seems to help some people with catatonia. Transcranial magnetic stimulation (TMS) is a potential treatment for catatonia, though the evidence is preliminary.

For less severe forms of catatonia, formal treatment may not be needed. Catatonia is not an extreme enough symptom for me to need treatment for it. Things that have helped me personally are grounding exercises and anxiety coping mechanisms, as anxiety from catatonia can often aggravate it.

If you experience catatonia, you are not alone. Since the condition is not well known and carries some stigma, it can feel very isolating. But it’s far more common than people realize.

Please let me know your experience with catatonia in the comments or reach out to me through the contact form.

How Do I Know if I Have Dissociative Identity Disorder (DID)?

Disclaimer: I am not a licensed professional. I cannot diagnose you, and my advice should be taken with a grain of salt. I know what it’s like to be a system, but I don’t know your unique experience and if another diagnosis might fit your experience better.

“I love my job,” I told my therapist, detailing how the social interactions were challenging and invigorating.

In the next session, I walked in and proclaimed, “I hate my job!” and detailed all of the horrible interactions I had to deal with every day.

My therapist smirked and took down detailed notes to confront me with later. Alex would front (take over the body) in the mornings for our sessions, and he loved the job, and I would front in the afternoons and absolutely despised it.

Anytime I’d go out to eat, it felt like I had many different voices talking over each other about what I wanted. Choosing was nearly impossible, and no matter what, it felt like I wasn’t fulfilling my needs.

Sometimes I loved writing with a passion. Other times I couldn’t stand it.

My “style” consisted of various clothing styles across different genres. I had low-cut sparkly tops, cargo shorts, flowy robes, polos, and ripped jeans all in the same drawer.

If you asked me what music I listen to, I’d have to say “a little of everything.” And I didn’t mean that I mainly stuck to a few genres but was open to others. It meant I had playlists full of classical, punk rock, rap, country, EDM, folk, etc.

My gender expression and sexuality fluctuated wildly, but I never felt “genderfluid.” I felt like a man, woman, or trans at any time, but I didn’t feel like I was fluid between them.

I had male and female pseudonyms that I would use online in different interest groups. I wrote papers under pseudonyms not because I wanted to remain anonymous but because I “liked how it sounded.”

When I was upset, I acted like a child, my voice getting higher, my cognitive functioning through a fog, and only finding comfort in items “made for children.”

It’s easy to look back now and see how being a system affected how I interacted with the world. When I found out I was a system, there was a click. I finally had an explanation for my unstable, shifting sense of self (which had been misdiagnosed as BPD). I understood my “zoning out,” my dissociative hallucinations, rapidly changing emotions, and being told I was “like a different person” sometimes, and why I felt the need to have so many names.

Wading Through the Sh*t

I have Dissociative Identity Disorder. And if you’re here, you think you might have it too.

It can be scary suspecting you have the diagnosis. There are so many different sources pulling you in all directions.

When I looked up “Do I Have DID?” going through this process, there was quiz after pseud0-scientific quiz asking for your credit card information. There were articles pathologizing and referencing systems as if we were rare monsters causing chaos everywhere we go.

YouTube videos sensationalized and demonized the disorder, saying, “come one come all! See the DID System perform the fantastical switch to become a whole new person!” References to Split and other problematic media are littered with connections to real systems.

All the scientific articles were arguing about the existence of DID, with little on what it actually looks like. And if you want to find research from the last 10 years, you’re pretty much out of luck.

Tik Tok, Reddit, and other social media users have loudly degraded anyone public about being a system. When there’s so much wrong information and incentive not to figure out you’re a system, how are you supposed to work through your own experience?

Finding out you’re a system is not just about wading through pools of bullsh*t to find good information. It’s also about deconstructing what you’ve known your whole life of what it means to be a person.

A Breakdown of the DSM Criteria

Let’s first examine the DSM-V criteria for DID. Since I am American, this is the criteria I am most familiar with but the ICD criteria is similar. Try to read this non-judgmentally. You are trying to find a label for your experience, not fit your experience to a label. I’ve paraphrased the criteria below to help with readability.

Dissociative Identity Disorder Diagnostic Criteria (F44.81)

  1. Two or more distinct personality states with their own sense of self and change in consciousness, memory, perception, cognition, and/or sensory-motor functioning. Discontinuous sense of self and agency. It may be described as a possession. It can be noticed by the individual or other people.
  2. There are gaps in remembering everyday events, important personal information, and/or traumatic events beyond normal forgetting.
  3. Clinically significant distress or impairment in functioning.
  4. Not attributable to cultural/religious practice or physiological effects of a substance or medical condition. In children, it can’t be better explained by imaginary play.

(American Psychiatric Association. (2013). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). doi: 10.1176/appi.books.9780890425787.x08_Dissociative_Disorders.)

It’s one thing to look at the criteria, but it’s another to understand it. One of the difficulties of any diagnosis (but especially uncommon diagnoses) is that it’s hard to know what the symptoms look like in application.

Criteria 1 Examples: Two or more personality states

  • Your brain functions like a conversation of multiple people talking or thinking at once
  • You hear voices that aren’t yours
  • You regress significantly and feel powerless
  • You regularly feel like you’re a different person altogether, or others have mentioned you’re a different person
  • You’ve had an experience of possession
  • Your preferences shift dramatically, you may have opposite food, gender, etc. preferences, and this happens regularly
  • You have body or gender dysphoria
  • Others comment that you sometimes talk or act differently, or you’ve noticed this change. This could be significant changes in vocal tone, vocabulary, posture, situation assessment, facial expressions, etc.
  • You feel non-human at times or like you’re the wrong age
  • When someone mentions you did something, you don’t feel like “you” did it
  • You can identify distinctly different “versions of you”

Criteria 2 Examples: Gaps in Memory Recall

  • You cannot remember a period in time beyond what would be considered normal forgetting (e.g., you can’t remember anything between age 12-13)
  • People mention how forgetful you are, or you notice you feel your memory is unreliable
  • You can recall specific memories very vividly sometimes but can’t remember those same memories at other times
  • You remember details of an event but can’t remember anything emotional, as if you read it out of a newspaper instead of experiencing it
  • You sometimes forget your name, address, phone number, or other vital information
  • You minimize when you do forget something most people wouldn’t forget, blaming it on other factors like being tired
  • You can’t remember a particular location at all that you visited frequently
  • You find yourself “waking up” somewhere, especially when stressed with no recollection of how you got there
  • You sometimes forget significant skills like driving, your job, your ability to write or speak, etc., especially while stressed
  • You recall the same memories very differently at different times, with no explanation for why your viewpoint changed
  • You have to write things down regularly if you want to remember them. You find notes you don’t remember writing

Criteria 3 Examples: Distress or Impairment

  • Your poor memory makes it difficult to work, attend school, parent, or take care of yourself
  • You feel haunted by not knowing parts of your past
  • Being a different version of yourself makes it hard to maintain friendships or has gotten you in trouble at work, school, or in public
  • You struggle to date because there’s a conflict in your head about who you’re dating, or your partner complained that you were “inconsistent”
  • You struggle to remember important deadlines or meetings
  • Losing the memory of how to perform certain skills makes it difficult to take care of yourself or affects other areas of your life
  • You find it overwhelming that you can never make a consistent decision on a direction in your life or a sense of self
  • You spend an inordinate amount of time deciding what to eat, wear, listen to, and it makes making any decision difficult
  • You feel like you have no control over your life
  • You regularly feel helpless
  • You feel like you’re constantly on the verge of a breakdown
  • You struggle to maintain relationships because people have said you’re “unreliable,” “wishy-washy,” or “unstable”
  • You experience any of Criterion 1 or 2 symptoms, and that causes you trouble in some area in your life or a lot of stress

Differential Diagnosis: The Biggest Risk of Self-Diagnosis

This is where Criterion 4 comes in. Self-diagnosis is sometimes necessary, especially when only 55% of clinicians believe the diagnosis is valid. Unfortunately, many clinicians don’t have any experience diagnosing DID, and the psych field has not treated DID systems well. That leaves a lack of information in a situation where a professional diagnosis is needed.

I am not against self-diagnosis because financial and cultural barriers are insurmountable for many minorities and impoverished people. This is an unfortunate reality of our current medical system.

But there are dangers to self-diagnosing DID that need to be addressed. The most significant one is differential diagnosis.

Since DID is so complex, many disorders mimic DID symptoms that may be difficult to spot without a trained eye. If you misdiagnose yourself with DID when you don’t have it, this could have serious consequences.

For example, simple partial seizures are where someone is fully aware but frozen. They may experience hallucinations, deja vu, and headaches. All of these symptoms may mimic a dissociative episode and cause a misdiagnosis.

Absent seizures (the most common type) are similar, where a person freezes and gets a blank look on their face. It is very short and results in a lapse in memory. This can look like dissociative amnesia.

The only way to diagnose seizures is through an EEG which requires a doctor. The last thing you want to do is have epilepsy and misdiagnose yourself as having dissociative identity disorder. The two have very different treatments, and untreated seizures can be fatal.

DID and epilepsy can co-occur as well, so it is worth looking into even if you receive an official DID diagnosis.

A few other differential diagnoses that are important to rule out are BPD, characterized by a discontinuous sense of self and dissociation similar to DID. OSDD is characterized by dissociative amnesia without alters, vice versa, or other specific circumstances (like intense brainwashing or only occurring for a short time). PTSD – which could present as gaps in recall or personality disturbances. Schizophrenia – shares psychotic symptoms with many DID presentations, and negative symptoms could be interpreted as dissociative or personality disturbance.

If you have the means to get a diagnosis, it is important that you seek a professional for DID. If you’re looking for a website to help find someone that can diagnose DID, try this or this.

If you don’t have the means, you are welcome to self-identify but know that there are certain risks of missing a serious medical or other psychiatric condition.

Now What?

After reviewing all the information, if you feel like you are a system, I recommend checking out my next article, I Think I have DID, Now What?. I detail common experiences of newly discovered symptoms and resources you can utilize to further investigate your experience.

Is “Pairing” in ABA The Same As Therapeutic Rapport?

CW: The following article discusses the implementation of ABA interventions. Reader discretion advised.

I was sitting with my non-speaking client, him holding up some blue edible playdough his mom made. I smiled back, and we both snuck a bit to eat, enjoying the salty-sweet-doughy taste.

I had spent weeks just playing with him, developing a relationship. He felt safe and loved because I played with him and gave him my full attention.

A couple weeks after that, I began implementing his programming. Our fun playdough time of making weird shapes and eating the playdough turned into a rigid activity to teach him letters.

I asked him, “touch A!” as I laid out letter stencils. If he chose the correct one, I would press it on the playdough, and we would get to play with it. He enjoyed our game and responded correctly the first few times.

I was inexperienced and didn’t understand autism well enough at the time to understand the following events. He seemed happy, grinning at me and playing with his playdough. I felt pressured to get in as many trials as possible, counting them on my iPad because they proved to my superior that I was a good therapist.

I pushed him repeatedly, rewarding him only when he gave the correct answer, or I grabbed his hand and had him touch the right answer. I followed the prompt hierarchy like I was supposed to.

Suddenly I asked him, “touch O!” and he threw himself onto the ground, banging his head and crying. I was distressed, trying desperately to calm him down. I put safety mats under his head and panicked, telling him it would be okay. Eventually, I learned that if I stopped talking, he was able to self-regulate.

I didn’t understand how our positive relationship had instantly turned into a distressing one. It seemed like the behavior “came out of nowhere.” I didn’t understand the stress he felt when I switched from showing him unconditional positive regard to suddenly making it conditional. He wanted to do what I asked because he cared about me, but I wanted more and more and more.

I was doing a process called “pairing” in ABA. Pairing is the process when a practitioner develops a relationship with a client to become a source of reinforcement themselves. When the therapist is a reinforcer, success in changing behavior in ABA skyrockets.

Often the first few weeks with clients are spent exclusively pairing. From an ABA therapist’s standpoint, the benefits seem like a no-brainer. The kid should want to spend time with you and enjoy your time together. You should learn what they like and don’t.

For survivors of ABA, the motives are more sinister. Pairing has been called manipulative because many therapists then weaponize that relationship to gain compliance.

Both have strong arguments with significant consequences. Therapeutic rapport is well documented as one of the most necessary steps in therapy, but it creates harmful results if it is manipulative.

So, is pairing manipulative or good therapy?

Therapeutic Rapport

Therapeutic rapport has been long established as a necessary part of successful therapy and medicine.

Research on therapeutic rapport suggests that to develop rapport, a therapist or other healthcare provider should use active listening, maintain an open posture, be honest, and alter their behavior so their client can interpret it (pg. 151).

Clinicians must focus on cultural competency with therapeutic rapport and considering their client’s unique circumstances. When there is a discrepancy in power, whether cultural, economic, or social status, there’s an increased need for caution. A therapeutic relationship could quickly become manipulative or harmful if these factors are ignored.

Altering behaviors so clients can interpret them is especially relevant to autism. A therapist’s body language must be able to be interpreted by their autistic client, and consideration taken for whether their body language can be easily decoded. Without this, the therapist could easily convey meanings that are not intended and/or further distress the client.

Eye contact is also something that should not be present in therapeutic rapport for autistic individuals, though this is often recommended. With non-speaking clients, active listening of vocal language may not be possible; though active attention to non-vocal signals is necessary.

So, therapeutic rapport for autistic people is necessary for robust therapy. Is pairing a good way to go about it?

Why do Some People View Pairing As Manipulative?

Love bombing is the process in which the person in the relationship is showered with gifts and positive regard with the goal of emotional dependence. After the person develops feelings for the person they’re with, the gifts and attention are removed and become conditional, creating an inconsistent, stressful environment. This can further lead to abusive situations if the person doing the love bombing isn’t receiving compliance.

“Lieu, this sounds pretty extreme. Weren’t you just talking about therapeutic rapport and its benefits to clients?”

You’re right, it is an extreme comparison. But it is necessary to understand the difference between healthy therapeutic rapport and manipulative rapport that fosters dependence on the therapist.

Pairing gives children unconditional access to reinforcers like their favorite items, activities, and even food preferences. The therapist provides the child with their full attention and doesn’t make any demands, showing interest in whatever they are doing.

After the child is bonded to the therapist, the reinforcers are conditional. The attention is contingent. And the child has to comply with demands to receive this loving support to which they’ve grown attached.

Add to this the power dynamic between an adult in complete control of the child’s access to their preferred items, with the powerlessness of the child to control what is targeted in therapy. The relationship is set up to create ethical issues.

That isn’t to say every relationship with children after pairing will become manipulative. But all it takes is one therapist who doesn’t apply a goal correctly, acting under the wishes of a parent over the child’s interests, or is facing pressure to meet a quota of goals. It becomes clear how this relationship could easily be weaponized.

Practices like “planned ignoring” and “extinction plans” require therapists to withhold their positive regard or access to reinforcement until the child completes the behavior they need to see.

This creates a distressing environment because children are desperate to get back into the therapist’s favor. They want that positive attention and want to feel loved by their therapist. Making that contingent teaches children several problematic lessons like compliance as love, non-compliance as unworthiness, and positive regard being conditional.

“Pairing is Just Therapeutic Rapport!”

Now that we’ve examined therapeutic rapport and pairing, it is necessary to understand why pairing should not be considered therapeutic rapport.

One of the key things that separate it from therapeutic rapport is the intentional removal of reinforcement.

Imagine starting therapy with a cognitive therapist who showed unconditional positive regard, openness, and altered their behavior to help you interpret it. You feel comfortable expressing your vulnerabilities and may even cry, breakdown, or tell them things you’ve never told anyone.

After five sessions of doing this, the therapist suddenly becomes cold and closed to you. They tell you for therapy to work, you have to stop crying when you come into therapy. It’s labeled as a “maladaptive behavior” and targeted for reduction. When you go the whole session without crying, she smiles at you and shows you the same level of attention you received in the beginning. You may feel confused or distressed by this sudden switch in demeanor.

Would you go back to this therapist? What if you didn’t have a choice?

There’s no point in therapeutic rapport in any other therapy type where the aspects of therapeutic rapport are reversed.

Further, suppose this is at a clinic where the therapists receive little to no education on aspects of autism. They may be incapable of modifying their behavior to be interpretable to clients. They may assume that their behavior is perfectly fine and it’s the client that is refusing to make an effort to interpret.

“My Client Loves Being Around Me, I Would Never Harm Them”

It’s a thought I had when I was in ABA. How could I be harming anyone if I was met by smiles, excitement, and unprompted bids for attention?

I certainly had no intention of harming anyone. I was there because I wanted to help, and in my mind, I was! I was taught that a behavior change was a marker of success, so I was clearly succeeding through a tangible measure of progress.

I ignored how “maladaptive behaviors” that clients experienced during my sessions may be an indication that everything wasn’t rosy. I ignored the meltdowns, the non-responsiveness, the times when I pushed too hard or didn’t understand the cause of their behavior. I ignored my contribution to the behaviors that “seemed out of nowhere.” And I saw it happening with other therapists, but no one seemed to see anything wrong.

It’s a scary thought, but you can harm someone without intending to. And if you’ve dedicated years to something to try to help someone, you have a lot of incentive to ignore those adverse outcomes.

If you’ve read this far and are an ABA therapist, I genuinely applaud you. It’s hard to examine your own flaws, and it’s clear you’re trying to do better. Otherwise, you wouldn’t be here.

If you’re looking to do better, look into how to develop therapeutic rapport. Do research on autistic traits and how to make your behavior easier to interpret for an autistic person. And replace pairing with developing evidence-based therapeutic rapport.

Clients deserve transparency in their therapy, including their expectations beyond initial impressions. Don’t set a false expectation of the treatment you’re practicing through pairing.

I Was Part of the “Good ABA”

I became an RBT because I saw a real opportunity to help people.

A coworker mentioned that she had been looking into the voices of the autistic community. She said that there was a big push away from ABA. In training, they presented all the research that supports how much better autistic lives are because of ABA; reduced self-harm, aggression, greater adaptive functioning, and less family stress. With that kind of evidence, who could possibly be against ABA?

Our clinic was a part of the new “good ABA.” It checked off all the boxes of what to look for in ABA clinics; “child-led,” “natural environment teaching,” “reinforcement, not punishment focused,” “communication driven,” and “not discrete trial training (DTT).” I was part of a force for good, part of the cutting edge of the field where ABA was seeing true reform.

Content Warning: this article contains descriptions of abusive therapy. Reader discretion advised.

It still haunts me hearing that electronic voice say “granola bar.”

The longer I worked there, the more I started seeing the red flags that weren’t visible when I initially wore those rose-colored glasses. It started with one of my favorite students, a nonspeaking child who was incredibly intelligent and very funny.

I could tell that he was bored with his programming. 90% of it was maintenance. He already knew how to perform the desired behaviors. They were still there because the BCBA and others couldn’t reliably get him to produce the behaviors.

We were encouraged to run DTT-style trials with him, where he would get frustrated easily to the point of self-harming. He was doing this with every tech three times a day, 40 hrs a week.

I started seeing other coworkers gossip about him, discussing how he was “manipulative” because he would seek reinforcement without performing “desired behaviors he knew how to do.” I couldn’t help but laugh at the idea of a 7-yr-old being “manipulative” of adults around them.

That kind of thinking was what led to my first instance of seeing something so morally abhorrent that it was impossible not to speak up. I shadowed another RBT and watched the student request food on his AAC device. Previously, the supervisor had set up an eating schedule for the kids to eat their lunches during the school day, and he was out because of training.

The RBT gently told him no, that he would have to wait for lunch, and he went and played. He continued returning to his AAC, asking for food, and the RBT continued to deny him. I watched this slowly escalate over 30 minutes until I saw the student start breaking down crying. He brought her to his snacks and pointed at them, and the RBT continued to say no.

I urged her to let him, but she brushed me off, saying that it would be “reinforcing maladaptive behaviors.” He went to other staff and brought them to his snacks, and everyone ignored him because he was exhibiting “attention-seeking” behavior. He manded over and over again, and it still haunts me hearing that electronic voice from his AAC device say “granola bar.”

I had enough and sat him at the table and gave him food. He continued to cry softly as he ate his snacks, so emotionally overwhelmed he couldn’t stop. I told my supervisor about the incident, and she wrote up a “training protocol” that was posted on the door of how lunchtimes were flexible.

I asked if she was planning on telling his parents, and she said, “What is there to tell? A kid having a problem behavior for food? That’s nothing new. We don’t report that kind of thing in our clinic, and if we did, there’d be way too many things to write reports on!”

 “It’s like he had PTSD or something!”

That’s not where it stopped. Shortly after, another supervisor bragged in a staff meeting about their research on the IISCA and a functional analysis they ran on a nonspeaking child.

The child had a history of self-harm and aggression, so they were trying to target the behavior so they could “turn it on and off at will.” They first gave the child homework and a bunch of puzzles all mixed together, so there was no solution.

In response, he didn’t have a “maladaptive behavior,” so they were forced to escalate. They started yelling at each other from across the room (knowing this kid had extreme hypersensitivity to noise) and banging items around the room. They brought in a speaker to blast music that the kid hated. The music was so loud it could be heard in other rooms.

He continued to self-regulate and didn’t have a maladaptive behavior. They started forcing him to watch clips of TV shows he hated and did all of these aversives combined, trying desperately to produce a behavior.

Finally, what broke him after 20 mins of what I can only describe as torture, they let him get up as if to let him leave and then forced him to sit down when he had reached the door. The kid started crying, and they considered the functional analysis a success.

I was horrified as my supervisor enthusiastically told me how much better he was making this child’s life. All I could feel was the deepest pit in my stomach, knowing how horrible my own sensory problems were and imagining that on a child who could not stop it.

In a staff meeting, the BCBA joked that “it’s like he has PTSD or something” when discussing him avoiding the room they were in, both supervisors and the RBT who were present at the time. She discussed how frantically he would act when she would even start to blast music to “turn on the behavior” and how quickly he would scream “my way, my way, my way!”

She said all of this laughing and boasting about it, and I looked around and saw my coworkers laughing with her. They didn’t understand how cruel it was. They had no training on dealing with sensory regulation in autistic children.

Every clinic considers itself to be the “good ABA.”

This clinic considered itself part of the “good ABA” and still does. I had no idea how to report it and was traumatized by my experience. I had heard about how stringent the BACB was with documenting events to take a case seriously.

At the end of this, I didn’t have enough documentation to feel like they would genuinely do much, especially hearing their inaction at even more significant ethical violations like JRC’s use of GED shock devices. I could already envision the slap on the wrist or, worse, complete dismissal “proving” my supervisor in the right.

I went public with the information, knowing I would be terminated.

Statistically and anecdotally, not every clinic can be the “good ABA.” It’s so easy to lose sight of what’s happening when you’re hearing things described in more appealing language. When valid criticisms are raised, ABA therapy has historically been morally disengaged.

I urge practitioners to watch the reaction of refusing to acknowledge harm when presented by autistic people, by coworkers, by supervisees, and by that feeling in the gut that something isn’t quite right.

It’s time the field listened to autistic people, especially when it’s difficult.

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