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

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.

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