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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