Editor’s note: As an publication, we have been critical of ABA therapy for autistic children. We have decided to publish this article written by a guest contributor, a non-autistic BCBA, because the content is relevant to our values and the emotional health of our autistic children.
I have been a BCBA (board certified behavior analyst) for over 10 years. I was trained at a “great” ABA (Applied Behavior Analysis) program, and I believed in ABA, just how I was trained.
I have worked in state hospitals, group homes, schools, home and community settings, and more. I developed a breadth of experience, and with every experience I gained, I grew more and more disenchanted by ABA.
I have made my mistakes along the way, I will admit and I have done things I was trained to do (not just looking at you planned ignoring and escape extinction) that I am deeply saddened by and regret. I learned things I did hurt people and still struggle to come to terms with my actions, especially as I feel trapped in this field.
My words here are a plea to ask that ABA practitioners consider the impact of how they practice therapy. They are not in any way intended to be against the code of the BACB (specifically sections 6 and 8, since the code engenders fear about speaking out against ABA). My words are here to address the shortcoming and failures in how we practice, specifically with autistic children.
Post-publication edit: Disturbingly, as of today, June 2, 2020, all versions of the ethics code and even articles referencing the code have been removed from the BACB website. A copy of the code can be accessed here.
I know this conversation is needed, that ABA needs voices pushing for this change, and spaces for this conversation to be had. Science evolves. We should not fear to have open, honest, and especially critical conversations about the state of the profession.
When a field resists change, growth, and evolution, it becomes a dogmatic echo chamber and encourages tacit complacency from those who don’t see themselves as part of the problem.
But where to start?
ABA likes to operate in isolation. The main autism treatment model is set up for a BCBA to oversee a behavior tech (a person trained usually with just a crash course in basic ABA and often in problematic and rigid teaching techniques (e.g. discrete trial training, planned ignoring, etc.) in a home or clinic.
If you are in-home, you are pretty much alone as a BCBA or BT with very little opportunity to grow collaboration skills.
In clinics, it is usually an office with an echo chamber of ABA people. We are trained in ABA and in none of the new advances in understanding of the brain, trauma, child development, and social/emotional learning.
ABA must humbly collaborate with these professionals and accept their research as valid in order to create approaches that attend to the social, emotional, sensory, and physical wellness of the whole child. There are some who are trying (ACT, DNA-V, practical FBA, etc.) but they are considered fringe, 3rd wave, new, and too focused on internal (read: emotional or developmental) “stuff,” according to the repeated complaints from BCBAs about them.
Just listen to any ABA podcasts on these topics. Behavioral Observations receives repeated questions from listeners whenever these topics come up, and they always center discourse around, “Is it really ABA?”
Or even worse, these techniques are used to make parents ignore their own feelings of trauma and pain when being told to use ABA strategies with their children.
ABA professionals are given a framework of deification with our ABA gods (some are calling out the problem with this, but not loudly enough) and admonished if we question it. Indeed, on one of my first days of grad school, my class was told: If you think you have any new or great ideas, you don’t. Someone already thought of it.
Anecdotally, many ABA students report feeling like their university program didn’t want them to “like” other professions. Mine specifically discouraged us from collaboration with social workers and school psychologists by insulting their professions, students, and professionals.
This isolationism carries over into our collective actions as professionals- when non-ABA professionals criticize ABA, our profession circles the wagons and vigorously counters by going into ad-hominem against other professionals and labeling them “mentalists,” hurling accusations of “not evidence based,” or worse, as being a part of the problem.
ABA seems so afraid of collaboration, many in ABA discourage “dilution” of ABA services to make sure no other therapies are involved.
Just as there is a need to collaborate better with other partners and seek to incorporate scientific research that originates outside of the ABA world, we must collaborate with our clients, especially our disabled clients.
Our clients are the experts in their own lives and know better than us what makes for a happy, healthy, and productive life for them. We can’t do better by our clients without listening to our clients. Too often, we impose our vision of their own lives onto them, with the arrogance that we know better.
Or, we choose to not believe clients and parents when they give us information. Truly listening to our clients and acting on their wishes, their vision, their values, their goals and how they want to achieve them is paramount and should lead to a full world of naturalistic learning rather than contrived reinforcement.
When we work to collaborate with our disabled clients, no matter age or ability, we elevate them to the level of respect that we, as a field, give our typically-developing clients. When we work toward collaboration with our clients directly, we actively work against this discrimination with treatment that ABA perpetuates.
How we treat the voices of dissent
Autistics have been decrying many of ABA’s techniques and approaches for a long time. Personally, I started learning and listening to autistic voices when I stumbled across the Wrong Planet forums. Sadly, it was still a very slow process to learn to listen in the way a true ally would.
Though I am a person of color, we (generally-speaking) white, neurotypical therapists in positions of power have been consistently working to dismiss, explain away, diminish, or outright attack those autistic voices.
We use whataboutisms as if we were trained to wholesale dismiss concerns by saying, “All professions have a checkered past,” and “That it is just a few providers,” and “ABA doesn’t do things like address stimming or force eye contact anymore” (spoiler, we do! We tell critics: “I don’t do that, I do good ABA,” (#notallABA)– while turning a blind eye and refusing to take ANY ACTION.
Social media is awash with these scenarios repeating over and over. If we were to truly care about our field, our clients, and ourselves, we would work to address and end bad practices we KNOW exist in ABA, the exact practices our many clients and critics repeatedly bring to light.
If we are going to defray criticism by saying “we” do “good ABA,” then we have a responsibility to be better; to be a LOUD VOICE actively addressing those among us that do harm by not living up to what we claim is our practice.
Caring would be working to correct our problems that our critics, especially critics that come from the primary community we purport to serve, bring to our attention.
To belittle them? To explain it away as misunderstandings? Why aren’t we listening? Why do we only tolerate autistic people in our space when they are our token cheerleaders?
Why aren’t we responding to voices of dissent? Why are we waving them away with meaningless platitudes: “We have heard you, and we are changing”? Why aren’t we giving the critical voices positions in our committees where, currently, we have exalted ABA professionals dispensing decrees as if ABA is the only way and needs no change.
I’d hope we’d all decry an all-white diversity panel, rules about women’s bodies made without women, or a paper about what low socioeconomic status families need without even asking them.
Why then, do we do this to people with disabilities, autistics, and other neurodivergent diagnoses? Why is it, when we have autistic voices willing to tell us what they think, we choose to deride them, instead of including them? We must do better.
How we treat those with disabilities
I had a moment in my career when I was trained on sexuality and rights on the issue of consent. I could not believe that this wasn’t an emphasis or requirement for our education, especially with how much personal physical space we occupy with our clients.
Long-term impacts of poor modeling of physical boundaries can be disastrous for clients.
Some BCBAs, especially the ones with experience and training only in autism ABA (not to be confused with actually knowing anything about autism), have a hard time explaining how apply ABA with neurotypicals and what to do when working with neurotypical adults, neurotypical kids, and society on a grand scheme.
It requires a lot of understanding of behavior, being accepting of internal states, and figuring out alternatives when the NT client says “no,” to really be able to practice better.
Autism ABA and Bias
The application of ABA with people with disabilities (including neurodivergent people) is different from the other applications of ABA (geriatrics, neurotypical adults, staff development, health and fitness, etc.).
ABA makes billions of dollars off treating autistics.
The ABA industry uses methods derived from a tired approach from more than half a century ago and have barely made any changes in teaching for autistics despite many fields (including those of developmental disabilities) moving forward while we dig our heels in the past. ABA needs to be better (NOTE: ACT is not doing better).
We cannot continue to treat autistics, neurodivergent people, and developmentally delayed people as “less than.”
The way we treat them now regards them as “less than.” Autistic consent matters less than other people’s. ABA therapists commonly run plans on autistic and other disabled people that they have not bothered explaining to the children– this is exponentially worse if the child is non-speaking.
Simply outlining a plan to a parent or guardian is just not good enough. What would our tolerance be for this if our own care providers operated without communicating directly to us?
Imagine (or maybe you don’t have to since this is a common occurrence in ABA) a child with a new ABA therapist or new demand screams every day for a while during ABA. What child development research recommends to do in this scenario is to empathize with the emotions and help the child work through them, reducing stress until the child feels safe and ready to learn.
What does ABA do with autistics? Escape extinction for the win! Ignore-and-redirect for the win! No concern for the child’s feelings. Little effort made to make the learning environment more tailored to their needs. Nothing about child developmental needs are incorporated into ABA’s work with autistics.
Meanwhile, we give them terrible coping techniques like asking them not to show their feelings and to eat their feelings (suppress them) with pieces of candy. This also reinforces to the child that their dissent, choice in how they learn, consent, and voice, don’t matter. ABA teaches autistic children to shut up and fall in line.
Compliance and Consent
Teaching obedience without question is, frankly, terrifying– especially since teaching blanket compliance to authority grooms people with developmental disabilities to be even more likely to be taken advantage of, abused, and bullied. ABA therapy has also just coerced them into silencing their internal and external “no.”
If I were an adult with skin picking, suicidal ideation, and anxiety, and I went to a provider for treatment, I would have tremendous say on which of these issues were addressed, how we address them, when, where, and in what way they would be treated. If I were not listened to, the provider would be quickly fired.
However, an almost-universal hallmark in ABA as applied to autistic people is that programs for behavior modification are built without ever considering the consent or wishes of the actual person.
We are so unprepared to work within the bounds of consent granted by an autistic person that we often totally neglect it, even in cases working with adults where we are legally required to seek informed consent.
We write blanket following instructions (i.e. noncompliance) as a targeted behavior for behavior reduction in plans for non-conserved adults and then pretend the adult actually gave us informed consent.
We often play games with consent and say the parent is giving consent, but remember the enormous position of power we, as BCBAs are in: We are the “PROFESSIONAL.” We are often viewed as “the cure.” (Which is gross, but that is how we often market ABA.)
We are “the answer” (cue melodramatic holy light shining down). We tell parents that we are the only way to help their child. We throw “evidence based” out like it means “proven to work.”
Parents are in a very vulnerable position, and we monetize that, all while ignoring (if we ever bothered to understand it in the first place) the wishes of the person that we purport to be our “client.”
How we speak about autistics and other neurodivergent people
Autism $peaks is one of the worst offenders of violating the preferences of autistic adults and is generally viewed poorly by autistics. ABA and A$ are often partnered and perform as a united front against autistics.
Are we as a field even aware of A$’s many controversies or of the profound dislike the vast majority of the autistic community has towards AS? ABA professionals often use cure language and participate as ABA organizations in “walks for the cure!”
We often talk about autism as if it is a disease or a public health crisis, a tragedy.
We participate in a conversation that demonizes the population we exist to serve, and we allow discussions about autistic people using language and imagery we would never tolerate being said about ourselves (even if it marginally improved our fundraising)!
We pride ourselves in our operational definitions and the idiosyncratic language we reserve for our field. Heaven forbid if someone uses “negative reinforcement” improperly around a BCBA because you’ll get a pedantic lecture– but we resist identity-first language (autistic, as opposed to “person with autism”) as if it matters more what we prefer instead of (once again) caring what the main population we work with wants.
In the same way you wouldn’t misgender somebody by ignoring their preferred pronouns, stop misidentifying autistic people who have clearly and repeatedly made their language preferences known and hold those preferences by a strong majority. If you would misgender someone just for your own comfort, then you are probably teaching gendered programming to autistic children without consent.
Yes, this happens; how many times do ABA professionals encourage traditional gender roles in children under the guise of social skills? Have we thought critically about doing that? Have we considered that the autistic population is enormously more likely to be LGBTQ+, including 10x more likely to be gender non-conforming?
Continuing to try to modify someone’s gender expression would keep in the long tradition of ABA’s link to gay conversion therapy.
If it is news to you that the overwhelming majority of autistic people prefer identity-first language (despite virtually all of them being told by others that the way they prefer to be referenced is wrong and the “right” is way person-first language), I would challenge you to honestly consider how much interaction you actually have with any autistic people.
Can you truly claim allyship with a group when you don’t know things as basic as how that group prefers to identify?
How we address internal states
ABA professionals like to say, “It’s not that we think internal states don’t exist. We just can’t measure them, so we don’t work with them.”
That is pretty scary.
We should be saying: we haven’t developed consistently good ways to measure internal states, but we are constantly working on improving by consulting autistic people (note: throwing “have you looked at ACT/RFT/DNA-V/etc.” at this problem doesn’t change that).
ACT (acceptance and commitment therapy) being implemented by BCBAs is a terrifying prospect. ACT is PART of a theraputic approach for helping clients. ACT is used, usually by mental health counselors, to help with persistent difficulties with thoughts and feelings by helping clients reframe their verbal language into different context to make behavior changes.
For BCBAs, it also requires a pretty firm understanding of relational frame theory (RFT), the ABA tie to ACT. Instead of using it appropriately, BCBAs weild ACT to claim they are working with covert (feelings and thoughts) behaviors without actually acknowledging how important a complete picture of a person’s mental health is to changing difficult internal feelings and thoughts long term.
Take this study as an example. Parents were trained to show “overt” behavior that looked like increases in values behavior (behavior that tied into your personal life values). In fact, the study reported that since ACT’s sole goal is to increase overt, value-driven behavior, that overt behavior should be the primary measure of success, not reported feelings or indirect measures.
The study specifically stated they didn’t concern themselves with mental health screening since they didn’t want to address that– so poof, they just pretended it didn’t matter.
Where are the fail-safes? How did the BCBAs know there was no trauma or abuse in the parents’ histories? How do BCBAs know they aren’t unintentionally teaching kids to strengthen aberrant coping skills, like shutting down feelings?
The terrifying thing is ABA practictioners do not know how to navigate these issues (because we are literally not trained), but instead use things like ACT as shiny new toys to play with. Like everything in ABA, ACT gets taken, broken down, and turned into an acceptable form of therapy in ABA: only what you can see matters. When all we care about is what we can see, we miss a lot, including masking (see below).
Internal states are integral to how stimuli in the environment change for the individual. Internal states change how much response effort you are able to give. Internal states change how aversive a stimuli or activity is (or one small thing within that activity).
Internal states change how reinforcing an item, person, or activity might be. Internal states alter our delayed discounting and pretty much all behavioral economics. Internal states exist and can change very rapidly.
Internal states can only be measured by the impact they have on the environment, including other humans. We could come up with great ways to see, define, and measure internal states, but we are trained not to question what we already do in the field.
There is an abundance of research across many fields (neurology, psychology, medicine, etc.) that tells us emotions, emotional regulation, sensory processing, self calming, etc. are integral to developing a child’s resilience (a positive long term outcome).
It’s also known that neurodivergent children have difficulty with these skills, and that these skills are foundational building blocks for all areas of learning and development for the future. We know how important it is for caregivers to be the teachers and for the role of professionals to help the child and the parents and other care sharers to develop positive relationships.
There is abundant research on trauma and the effects of chronic stress on a child’s threat system. Neurodivergent kids and adults are more sensitive to trauma and stress. Trauma research also shows the different ways trauma manifest– there is a reason ABA kids get called “calm, quiet, compliant” and its called the freeze shut down response.
Unfortunately, all of that is internal, so ABA wants to plug its ears and look away. Why? Picture a 3 year old kid being forcibly separated from their parent for ABA. Child is screaming while ABA therapist holds a fighting kid in lap. Kid kicks off shoes and is freaking out, screaming, flailing, now on the floor. Kid is ignored and monitored. Data is collected.
When the kid is quiet, the therapist tells her to put her shoes back on. Child melts down again after just having to work out emotional regulation with no help from caring adults. Hand-over-hand (a violation of bodily autonomy) to put on shoes from large, powerful adults and brought to circle time to learn songs and colors despite probably still being in a neurophysiological state of escalated stress (a.k.a the opposite of an optimal learning context).
In the end, the therapists will get their data and call this child “improved” as the girl has given up.
So much of what ABA does is not in alignment with current understanding of child development and brain science. It seems to line up more with methods that are linked to poor long term mental health outcomes.
The sad thing is, it could be changed. Saying “Have you seen our most recent research in (insert whataboutism here)” doesn’t change how we are educating our students and supervising our upcoming and new BCBAs.
We need a major paradigm shift.
A certainly not-final note on internal states– if we aren’t putting a lot of weight into internal states, we will fail to detect when people are masking, or pretending to enjoy what we have been “reinforcing” them with and speaking for them by telling them they enjoy it.
We won’t notice they are pretending that they are not stressed and anxious, from all the effort they are using in suppressing their natural selves. If we are only looking at what the person externally expresses, but we have reinforced them to express a certain thing regardless of how they truly feel, we are treading into dangerous territory, but more on that below.
Use of punishment, extinction, shock
Judge Rotenberg Center.
The Judge Rotenberg Center is a residential institution that has an infamous international reputation.
ASAN has so much important information about the Judge Rotenberg Center (JRC). BCBAs work at JRC, run the programs, and sit on the board– some of the most notable names in our profession sit on that board. They annually present at our most major yearly conference and are received with applause.
We give them a platform to present evidence-light defenses of their practices (like electroshock punishment used on intellectually disabled children) while neglecting to invest equal effort and equal energy to learning from the far larger body of more recent and more compelling evidence that would deter those practices.
We give JRC legitimacy, and then have the gall to try and distance our industry from those same practices when our critics mention them!
Our tolerance for JRC inhibits our growth in other ways. Because we tolerate JRC within our profession, we have a code of ethics that also tolerates JRC, and as a result ALSO would tolerate virtually every bad act done in the history of ABA, in 2020.
JRC may be only one place, but JRC BCBAs can leave the JRC and set up their shingle in another town with skills developed to do things the vast majority of our profession would never do and never feel appropriate to do. And they can do it all within our code of ethics.
We as a field should not be associated with this at all. In what world is it okay to attach a shock device to someone and give the power to shock them to other humans? Humans are flawed. There is no way to keep this humane.
Imagine having a hard time in life because of how disabling the world can be due to your sensory perception. Imagine being institutionalized (which research shows is ALWAYS associated with terrible outcomes) and developing trauma over your years of institutionalization– and now you get shocked for the behaviors you have developed to cope.
Shocking teaches nothing but learned helplessness and leaves no room for healing.
Extinction (including planned ignoring) goes against what all the research is showing us about child and human development. Extinction doesn’t care about trauma, in fact it can cause trauma.
We should have extreme trepidation about extinction and planned ignoring programs being run that have the effect of making the person feel that accessing love, comfort, reassurance, and affection in their lives is conditional to their behavior. Just because something works behaviorally doesn’t mean it is something a therapist should have in their tool bag.
We need to address the suicide crisis happening in the autistic community, and we need to honestly and critically consider the very real probability that we are contributing to that crisis.
The vast majority of autistic adults identify with having psychiatrically significant suicide risks, and research indicates suicide risk among autistics is TEN TIMES greater than the general population.
Studies researching this crisis, and a huge number of anecdotal reports by autistics reflect that a primary factor contributing to suicide risk is masking or “camouflaging” autistic traits- pressure felt by autistics to mask and “pass” as neurotypical or “allistic” people.
How often do we address stimming? How often do we write plans for forced eye contact and “whole body listening?” Research has come out showing us that eye contact can be physically painful. Stimming helps decrease anxiety and stress in autistics (and I’d say in most humans – check your own stim).
How often do we discourage autistic people from talking or learning about subjects they “obsess” over? How often do we encourage “age appropriate interests?” Have we EVER considered or put in writing an acknowledgement that we could be putting our client’s mental health in jeopardy by doing these things?
Why are we encouraging autistic people to present based on our version of normal instead of as unapologetically themselves with the skills to advocate for their needs as themselves rather than some theoretical “fixed” version of themselves?
Imagine you were hired by a gay high school age client. The client discloses that he is being bullied by his classmates because he is gay. Would you EVER, EVER, EVER consider writing a behavior program that taught this client to act in a stereotypically heterosexual manner to reduce bullying?
Now, be honest, and think to yourselves how often we give advice to autistic clients that they will be more acceptable if they can act more neurotypical, even if you don’t use those words. The autistic community has a term for this – a common critique of ABA – “Autistic Conversion Therapy.”
If ABA wants to keep up with what the mental health, medicine, and neurology fields have demonstrated is the best way for the village to help children, we must do something big and fast.
Change our education, change what is still acceptable, change our views, change the culture of ABA, change our ethics code. We must work together to do this, and that includes with other professions and especially with autistic people.
We have the research. We have the principles. We need to incorporate all the current outside-of-ABA research into ABA and use it as the starting platform for a path that leads us back to humanity.
Individual practitioners need to make change now. Waiting until the systems change will be too late for too many children. I have fundamentally changed how I work, but I grieve for those who knew me when I was a “good” BCBA.
I’ve finally been able to put an escape plan into action by starting work on a mental health counseling degree. My hope is to continue working to elevate the call for change in ABA while providing mental health services and trauma care to ID/DD communities.
I urge ABA practitioners to pay attention to autistics and make the urgently-needed changes to their practices. For any changes to have meaning, ABA professionals must also add their voice to the steadily rising call for systemic, cultural, and educational changes in the field of ABA.
- I am a disillusioned BCBA: Autistics are right about ABA - June 2, 2020