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The Changing Face of Autism Therapy: ABA is Down, Peer Mentoring is Up

The Changing Face of Autism Therapy: ABA is Down, Peer Mentoring is Up

Michael John Carley

Author, Consultant, New York University (he/him/his)

发布日期: 2022年1月23日

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(A little boy with a scared face holds a teddy bear while in a therapy session). By Michael John Carley Everywhere you look, Applied Behavioral Analysis (ABA) is either likened to torture, or at the very least, confronting an awful history. And yet it has a stronghold on parents and schools as the only universally-funded behavioral strategy for autism supported by state governments and insurance providers. “Life coaches” are springing up all around, but with no guarantee of a sustaining market—and have those coaches actually “walked the walk” in their own lives? Peer Mentoring is a tiny fraction of the available options—yet has no detractors. But of course I’d say that! Because it’s what I do! And that’s a good point to end this intro on because everyone has a financial stake in what gets called “effective,” and “proven,” whether they really are or not. The History… After my son’s and my diagnoses one week apart in late 2000, I went hunting for information like any other parent. I knew nothing. However much both my son’s and my new label made sense (“Asperger’s” then; and after re-evaluation in 2014, “autism”) this was uncharted territory for me. I was a “starving playwright” by night and a minor-league diplomat by day, and so even the phrase “developmental disability” felt exotically vague. He was 4. I was 36. On my search to sponge up the world’s knowledge, I saw gaps in the wisdom of “experts,” ignorance that attempted to invalidate all those things that had so benefit me in my decades as an undiagnosed spectrumite. I wondered why people couldn’t see the benefits of theatre—not just for the opportunity of creative expression in so many forms, but also for ironing out theory of mind issues (playing a character), or increasing an awareness of what your body was up to in a given moment. I wondered why people couldn’t believe how sports had helped me. I relayed how the larger benefits were in making me comfortable with competition, ironing out motor skills issues, as well as providing me with a safe environment to work through all those natural, uglier, human feelings…Herein, people could at least see the benefits of my arguments. But they weren’t prepared to “deal with” the emotional fallout that comes with the process of learning how to be a graceful winner or loser. Caregivers were “too tired.” In the autism world, we’ve gotten things wrong. And in behavior strategies, there was only one that had a resounding endorsement, ABA. In quiet pockets around the country you could find TEACCH—Treatment and Education of Autistic and related Communication in Children, an adaptive approach spearheaded by the wonderful Gary Mesibov. There was RDI (Relationship Development Intervention), Stanley Greenspan’s “Floortime,” the rather comedic “Son Rise” program…SCERTS (Social Communication, Emotional Regulation, and Transactional Support), the first approach that intentionally took ethics into account, was a few years away. But only ABA was thought of in the general lexicon as standard, proven, and reliable. Even in my community, the people on the spectrum themselves, there was little knowledge. Despite a few brilliant exceptions (a club I did not belong to), spectrumites who hadn’t experienced ABA firsthand were predominantly ignorant of what it entailed. Part of the reason why we didn’t see ABA’s problematic side was that with the separation of “Aspergers” and “autism” you had one community not so exposed to the other. Another reason was that ABA was so mysteriously hard to define. After I made the decision to switch careers into this new world, it became almost impossible for me to get some of the technique’s most prominent proponents to give me just a one-paragraph definition of the approach they swore by. And as I’d quickly become the head of the world’s largest membership organization for adults on the spectrum (GRASP, the Global and Regional Asperger Syndrome Partnership) it was a personal knowledge gap that annoyed, but didn’t overwhelm me. A third reason was that aforementioned point that we didn’t have the massive number of adults on the spectrum telling us about their childhood experiences with ABA.1,2 Now we do. And in what will hopefully not resonate as a confessional (as this may anger younger, fellow spectrumfolk)…the final reason was that some of those ABA proponents were the best neurotypical allies people on the spectrum had back then. We were all immensely aided by organizations like Long Island’s AHANY (now a part of AANE, the Autism Asperger Network of New England), who were heavily associated with ABA-centered organizations. Peter Gerhardt, now the head of the EPIC School, was one of really only three people in the entire country saying “We have to start listening to people on the spectrum!” (the others being MAAP’s Sue Moreno, and AHANY’s Pat Schissel). Gerhardt was also one of GRASP’s first Board members, wrote the Foreword for my first book, and is a genuinely gorgeous guy all over his insides. Deb Thivierge, head of the ABA-centered ELIJAH School, secured the restaurant for and hosted GRASP’s first four annual benefits. She too, shouted “listen to people on the spectrum” from the figurative rooftops. I’m not praising them because I “owe” them. They were for real, our best advocates. And they certainly weren’t hitting kids. Were all ABA leaders our friends? Did nobody in the ABA hierarchy resent those “high-functioning” adults for getting some of the autism spotlight? Of course not. I’m citing the heroes within, not everyone. But stuff was brewing. We all began examining everything deeper when both the vaccine controversy and Autism Speaks entered the field. Opportunists like Andrew Wakefield had existed prior to Jenny McCarthy, and parents had sick encouragers of anger and resentment like Lenny Shaefer, he of “the Schaefer report,” long before Autism Speaks’ ugly entrance. But until 2005 my first five years in the field were pretty peaceful. Outside of universal disdain for the Judge Rothenberg Center (where aides with only high school diplomas were allowed to apply electric shocks to unsuspecting residents whenever they wanted),3 …everybody kind of got along. Luckily, those mid-2000s also gave us luminaries like co-SCERTS author, Barry Prizant, author also of the iconic, must-read, “Uniquely Human.” Furthermore, a second organization run by as well as for adults on the spectrum, ASAN (the Autistic Self-Advocacy Network) emerged two years after GRASP. Combined, these and other forces looked at ABA with an eye towards measuring success not by “appropriate behaviors,” but instead through the lens of the autistic person’s mental health. My personal “ah-ha” moment came early on in my ten years moonlighting for the New York City Public Schools’ Special Education District 75. I had various groups of spectrum teens who were pretty verbal, but whom would need some level of assistance to live independently throughout their lives. And in our sessions—in-class, or out in the world—we tried to examine pretty much anything in life like work, dating, etc but with an eye towards how our spectrum lens might make us see each subject matter differently. At one session, I said to them “You guys have been fabulous this semester, thank you. You’ve done everything I asked, so this week I was thinking…what would y’all like to do? Name it, and I’ll try to make it happen.” Crickets. At first I thought they just were being shy and (as is common in the spectrum) uncomfortable with either change or the transition to self-initiation. So I elaborated on my question with not only more explanation, but also options to choose from. Crickets. These kids had been raised on nothing but ABA. And only then did I see that ABA hadn’t encouraged them to ask what they wanted out of life, but instead had gotten them to comply with what others wanted for them. The very concept that they might want something different from what the world wanted from them (“appropriate behavior”) was like asking them to describe a color they’d never seen. Their polite manners had come at perhaps a high cost. And as horrifying a realization as this might seem, my kids were also regarded as the lucky ones. All were kids of color coming from economically-challenged neighborhoods, that back then rarely received any diagnostic attention. ABA has since undergone massive scrutiny, and now what has become public knowledge are additional faults such as: ? A founder, Ivar Lovaas, who often hit children to get them to do what he wanted. ABA’s principal idea was based solely on compliance obtained through punitive, negative reinforcement. Parents had by then rebelled against Bruno Bettelheim’s “autism comes from bad parenting” ideas, and this was indeed progress. But these same parents were fine with Lovaas hitting their kids? ? ABA is the foremost therapy not because it is widely accepted. Its lobbyists (including Autism Speaks) have done an outstanding job of making it the only well-funded or reimbursable behavioral option for families. Frankly, it’s the only behavioral strategy that has (figurative or literal) lobbyists working on states and insurance companies. The stories of parents being hit, houses being somewhat destroyed, poop smearing…they’re not lies. ABA maintains its financial monopoly in part also because parents still want it. Overwhelmed families either frequently have no other choices, or are overjoyed to receive the often 40 hours a week of ABA therapy. Many of these families believe in ABA, but for others it is a respite for them—whether they like what it’s doing to their child or not. To many, it’s just free babysitting. Small wonder that venture capitalist firms are buying up for-profit ABA centers.4 ? ABA proponents will tell you that much of this monopoly on the market is based on ABA’s being the most effective, long-term approach based on the research…But what did this research look at? Quality of life? What kinds of questions were asked? Because while they looked at legitimate markers like educational and communicative advances, I suspect they mostly asked unknowing parents “Do you like how Johnny behaves now?” and unknowing spectrumites, “Are you happy?” wherein they would say an uninformed, “yes” only because their families weren’t as angry at them anymore. This research never looked at the trauma that might have been imposed—can you imagine 40 hours a week of your hands being constricted together every few seconds?5 And because the government funds ABA, many young people go into the profession (as opposed to, say, SCERTS trainings) because they won’t have to worry about becoming employed, staying employed, and because they want to help autistics (nobody goes into this field so they can hit children). And most, it should be said, are unaware of the awful history—the certification programs to become a BCBA, the acronym for an ABA therapist, certainly aren’t going to inform them. But ABA has also adapted, which I think is why it was once so hard to pin people down to a one-paragraph description. And many—maybe even most—have shifted from negative reinforcement when the child doesn’t do what they want, to positive reinforcement when the child does do what they want. But by design, ABA teaches the autistic person that their natural way of doing things is bad, and no matter how nice and caring the practitioner they work with, there is an indisputable loss of self-esteem that comes with a “do it this way” approach lacking the context that answers “Why?” The lack of explanation creates an inarguable wound to their permanent mental health and personhood. The cases of self-injurious, or violent kids do indeed require different measures. However, I firmly believe that these cases will steadily decrease as parents learn to create environments that make their kids feel more accepted and loved. That’s not to say that parents who had autistic kids from the 1960s to the early 2000s didn’t love their kids. But I can easily hypothesize that they didn’t know how to make them feel loved, especially when all the doctors were telling them to love their kid “but hate their autism.” That, they thought, was the best way to show their love. The studies that now look at PTSD6 and suicide rates7 in autistics are telling a new story. In the autism world, we’ve gotten things wrong. Long-Standing, Yet Lesser-Known Strategies Briefly… ? Floortime. It is as it sounds. The clinician (usually an Occupational Therapist [OT]) or parent looks to the child and their interests to lead. Then, in a play therapy context, the OT builds a relationship with the child through specific tasks. ? RDI. Somewhat similar to Floortime in that it can be implemented by parents, but only after a more extensive (and often expensive) training. The program is also more geared to six specific highlights—concepts that are used to fulfill the individualized goals set forth, usually, within the training the parents receive. The six are: Emotional referencing, Social coordination, Declarative language, Flexible thinking, Relational information processing, and Foresight and hindsight. RDI (also called RDI Connect) can be an interesting component to a behavioral plan. But to be fair, I’ve never heard of a parent raving about RDI. Some of their language also maintains a dedication to framing autism within an outdated deficit-model. ? TEACCH. Although fading somewhat these days, I always liked TEACCH because it really was the first approach to take the spectrum individual more into the process of becoming a second clinician rather than a patient. The process was also very transparent. It can be successfully incorporated into non-therapeutic/behavioral environments, like vocational programs. ? Cognitive Behavioral Therapy (CBT). Though still underutilized, CBT takes the patient-as-second-doctor approach into the therapist’s office. CBT may not be the be-all and end-all of autism therapies, but I’ve yet to hear a negative experience. A fabulous alternative to traditional talk therapy. ? Son Rise. Twenty years ago, the Founders charged parents around $30,000 to train them in a technique that basically demands the parent follow the child morning, noon, and night; and instead of redirect their autistic gestures, they’re instructed to respectfully mirror the child’s non-neurotypical behaviors. I laugh as I write that of course the reverse assimilation-thing that’s going on here is appreciated by me as an autistic, but clearly this is meant only for wealthy folks who don’t need to work. The child may herein feel accepted, but I’m not sure they’ll ever learn anything. ? SCERTS. My favorite of this bunch. Like some others, it employs the entire family dynamic. And were it not for the lack of a business model, many believe it would much more visible as an alternative to ABA. The “family dynamic” mentioned above could also be called essential. I certainly know, as a school consultant, how often one of my students went home, shared with their families what the student and I had done together, and received something akin to this response: “Mr. Carley said ‘what’??? No. He’s wrong. You have a disability. You’re flawed. And you’ll only be happy the sooner you accept that.” All our work therein to improve their sense of self…is flushed down the toilet. Families need the hope we bring, to know what’s going on, and often, to grow as human beings along with the child. Historically too, whatever strategy was chosen has been influenced by either a humanistic or negative approach to what made the child different. Were non-verbal children born into families that talked negatively about the child and their autism…while they were in the same room? Because the parents assumed they didn’t understand them? Maybe they even referred to the child as “dumb” while the child was near? Do we all finally understand how damaging that might have been to the child? In the autism world, we’ve gotten things wrong. The Future? Along with the rise of autistics being introduced to sports and theatre work, we've also learned to accept an idea that has yet to be implemented, but that was (and is) as “no-brainer” as it gets …The idea that no Ph.D. can equal lived experience. The real experts are us. Ph.Ds are by no means worthless. But autism organizations need to have senior leaders who are autistic. No school should be without an autism consultant who themself has autism. Peer Mentors (admittedly, like me) are having impact, where licensed therapists are not. Why? For starters the spectrum client doesn’t feel as though they have a ton of explaining to do for the benefit of the person in charge of their care. They can trust that they are being understood, and not just loved. We have trust issues for a reason. And no one truly gains our trust when their lack of knowledge is so evident. But we won’t tell you that because we often love you. And love and trust are two very different animals. All prior research done without supervision by autistics is even being talked about as tainted, and perhaps getting “cancelled,” like when the crooked cop is caught, and all his prior arrests convicted on evidence he provided…have to be freed. And the world need not be scared of this from an employment-pool standpoint because nowadays there are spectrum therapists, and spectrum researchers, consultants, and coaches. Having the diagnosis is not a small contribution to our résumé. It’s a game-changer for how effective we will be. (One sidebar about coaches of any kind, though? I’m a skeptic. I’ve always believed that any schlub can get a degree, and with so many uninformed and bogus certification programs out there, my cynicism easily extends to coaches. Peer Mentors get evaluated by whether they’ve “walked the walk” in their lives. But coaches can have employment and relationship histories that are absolute train wrecks, and yet can pitch themselves as authoritative successes because of their certification.) I also hate to pull out the most shamelessly blatant example, but since it holds up under scrutiny …Can you imagine a white “expert” on African-American studies getting away with saying they know more about the experiences of people of African descent…than the people of African descent? Especially under the auspices of “Well, black people are too traumatized to speak truthfully of their own experience.” Furthermore, look at almost any autism conference, and look at the post-conference, audience feedback forms. Guaranteed: Audiences report learning more from the speaker or panelists on the spectrum than the neurotypical keynote. And usually, the speaking fees are four figures for the keynote and two figures for the panelist. Where’s the disconnect??? Three Conclusions The aforementioned disconnect may be that we’re looking only through the lens of our humanity, our trauma, and our decreasing educational standards. We’re not looking enough at the money. The controversy over ABA may have so much more to do with ABA’s reluctance to admit its historical horrors because were they to figuratively apologize to the world, they’d then arguably have to admit that other strategies deserve a share of the funding—dollars that ABA still has such a large monopoly over. Maintaining eye contact was once brutally driven into people during ABA sessions, then it was merely encouraged. Now, many ABA clinicians consider maintaining eye contact to be of no concern. Why? Because the rest of the world changed and didn’t need eye contact to feel “respected.” Stims were once brutally driven out of people during ABA sessions, then discouraged. Now, many ABA practioners allow them. Why did this change? Because the rest of the world changed: It learned that stims are more often an expression of pleasure, and because the rest of the world stopped assuming that flapping hands revealed a potential mass murderer. All behavioral strategies change with the times Would Lovaas even recognize ABA today? Making the rest of the world more inclusive will always be the better choice over forcing assimilation. If any assimilation is to occur, it must be within the context of learning a new language rather than “Your way of doing things is wrong. Our way is right.” Early on in my career, I learned to respond to embittered folks who told me I “couldn’t have autism” by responding, “Just because I learned fluent French doesn’t make me French.” *** Rebecca Rosenzweig is 25 and from L.A. She first noticed an affinity with autistics as a teenager working at special needs camps, where she loved their company, and where more importantly, everyone noticed that they loved hers. She was steered into becoming an ABA Therapist, enthusiastically went for it, and right around the time she herself was diagnosed with autism, she caught wind of ABA’s history. She saw none of the historical horrors in what she or her colleagues did. But she acknowledged that she sees some stuff that bothers her too. She has since taught her firm about the humanity behind Proprioception, Echolalia, Synesthesia, Prosopagnosia, and what she finds disrespectful in their practice. She reports that everyone was receptive. And the fact that her superiors allow her to influence or train other staff?...speaks volumes. Agreeing with the humanist mantra that: Every behavior is a story someone is trying to tell. The good behavioral therapists try to find out what that story is. The bad ones just try to stop the behavior. …I therein felt comfortable asking her, “Would you accept though, that while ABA is undergoing positive changes, that it is still by design the only strategy rooted in negative, as opposed to positive reinforcement?” I’m still thinking about her answer; as it takes the “every behavior is a story” idea to what might be a new level. She replied that she thought that if no trauma was inflicted, that whether a reinforcement was positive or negative didn’t really matter. To explain, she summoned a memory of when she unknowingly “practiced ABA on myself.” “I used to have a really hard time reading…So when I had textbook homework, I would put a Skittle under each of my paragraphs. And then I’d say, ‘Ok, Rebecca, when you read one paragraph then you get your Skittle.’ You read another paragraph and then you can get the next Skittle. And that was essentially what they’re doing in ABA, right?...That got me through the reading. But did it get me to understand the root cause of why I was having trouble reading/make reading easier in the future? No.” *** I had noticeable eye contact issues all my life—until I was conducting my undergraduate thesis that concerned the Holocaust. As a non-Jewish, twenty-one year old having the gall to interview survivors who were old enough to be my grandparents, I felt incredibly inadequate, and undeserving of their willingness to unearth such horrible memories for my benefit. So in my guilt and commitment, I had to “ride the wave” of their narratives with them. That meant eye contact. I still remember how incredibly painful it was to my head. It affected my vision. I felt physically damaged for hours after each interview was done. But it was my choice to put myself through that. Now imagine a much younger child, being put through that without their consent…often for 40 hours a week; over years of their lives. Many will tell you that’s the price that has to be paid for someone to stop banging their head against cement. But how many of us spectrumfolk really demand that tough a choice? And can we really say that the person isn’t traumatized for life? Even if the individual was more than significantly-challenged, was it worth it? Be it the “cure” debate, or the vaccine controversy, our humanist side of autism has really never lost a battle, and we won’t lose this one. The only question is “when?” And I think an eye towards changing the funding structure is what will hasten the journey rather than personal attacks through Facebook. Then, maybe LinkedIn recruiters will go hot and heavy after SCERTS practitioners and Peer Mentors just as much you see them going after BCBA candidates. Our prevalence as spectrumfolk is now at 1 in 44. The market—the need for individuals, families, schools and businesses to get effective, humane educational assistance—keeps getting larger, and will continue to until all this stuff is just thought of as natural extensions of the human experience. References: 1. https://autisticscienceperson.com/why-aba-therapy-is-harmful-to-autistic-people/#where-to-start-for-support 2. https://neuroclastic.com/invisible-abuse-aba-and-the-things-only-autistic-people-can-see/ 3. https://www.nbcnews.com/health/health-care/decades-long-fight-over-electric-shock-treatment-led-fda-ban-n1265546 4. https://www.thenation.com/article/society/private-equity-autism-aba/ 5. https://www.youtube.com/watch?v=7pN6ydLE4EQ 6. https://www.emerald.com/insight/content/doi/10.1108/AIA-08-2017-0016/full/html 7. https://pubmed.ncbi.nlm.nih.gov/30083306/ Michael John Carley is the Founder of GRASP, a school consultant, and the author of “Asperger’s From the Inside-Out” (Penguin/Perigee 2008), “Unemployed on the Autism Spectrum,” (Jessica Kingsley Publishers 2016), “The Book of Happy, Positive, and Confident Sex for Adults on the Autism Spectrum…and Beyond!,” (Neurodiversity Press 2021), and the column, “Autism Without Fear,” which has seen exposure in Exceptional Parent Magazine, but also Sinkhole, and that for four years ran with the Huffington Post. Currently he is leading the “Connections” program at New York University for their worldwide autistic students, and he also has a private, Peer Mentoring practice. For more information on Michael John, or to subscribe to his free newsletter, you can go to www.michaeljohncarley.com.

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