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The Diagnostic Criteria for Complex PTSD (C-PTSD): A Beginner’s Guide

  1. What is complex trauma?
  2. Complex PTSD Criteria vs. PTSD Criteria
    1. PTSD Core Areas
    2. C-PTSD Criteria
      1. A) Severe and pervasive problems in affect [emotional] regulation.
      2. B) Persistent beliefs about oneself as diminished, defeated, or worthless, accompanied by deep feelings of shame, guilt, or failure related to the stressor.
      3. C) Persistent difficulties in sustaining relationships and in feeling close to others.
  3. C-PTSD vs. BPD
  4. A note on healing

While filling out therapy intake paperwork a few years ago, I stopped at a question that asked me to identify the worst event of all the DSM-5 traumas I’ve experienced.

My worst trauma? How was I supposed to choose between all of them?

I flagged reception and asked how I was supposed to fill it out.

She gave me a confused look and said, “choose the one that interferes with your life the most.”

That didn’t narrow it down. Why could I only answer questions about a singular trauma? And what about the traumas I couldn’t remember well?

It made it difficult to answer questions like “how often do you avoid memories, thoughts, or feelings about the stressful event?”

For the trauma I selected, I only avoided it a bit, but I spent a lot of time avoiding all of my traumas.

One of the questions was, “how often do you have trouble remembering important parts of the stressful experience?”

Naturally, I chose the trauma I best remember. So, if I were going off this, the answer would be “not at all”. But for some of my other traumas, I couldn’t remember most or all of the event.

The questionnaire used most often to screen for PTSD is the PCL-5, which assesses based on the DSM-5 criteria for PTSD. The problem is that the DSM-5 criteria are centered around one traumatic event while acknowledging that the symptoms can be caused by multiple traumatic events.

That means that in the U.S., single traumas and multiple compounded traumas are treated as the same, with no acknowledgment of how multiple traumas or minor compounded traumas could differ from a singular traumatic event.

There are some clear problems with not differentiating complex trauma and trauma from a singular event. The ICD-11, the most widely used diagnostic manual, has addressed these issues with the introduction of the C-PTSD diagnosis.

This diagnosis has been proposed since the 80s but was excluded from the DSM-5 as there was too much debate over whether the symptoms warranted their own diagnosis. Currently, the C-PTSD symptoms that are separated in the ICD-11 are included under PTSD criteria in the DSM. So, the symptoms are the same, but the question is whether they warrant their own label.

Personally, I think having it as a diagnosis is beneficial. It helps doctors understand the severity and pervasiveness of my symptoms, connects me with others who have experienced complex trauma instead of singular traumatic events and helps highlight specific symptoms resulting from complex trauma.

*Disclaimer* – This is an informational resource, not a diagnostic source. If you have the privilege to see a competent clinician with multi-cultural training, it is better to have a professional distinguish these conditions. We recognize that the luxury of a professional diagnosis is inaccessible to many, and they are left with the internet to parse out their symptoms. We empathize with this, which is why we give as thorough information as possible from the source while encouraging you to seek a professional when possible.

What is complex trauma?

I think a common reaction to hearing the phrase “complex trauma” is people thinking “oh, my trauma wasn’t that bad. It couldn’t be complex.”

Generally, the word complex comes with the connotation that something is worse, so complex trauma must be horrific.

A better way of thinking of complex trauma is considering it as compounded trauma.

The ICD-11 says :

Complex post traumatic stress disorder (Complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).

So complex trauma can be thought of as prolonged or repetitive and inescapable.

Child abuse is one of the most common causes of C-PTSD. Considering child abuse makes you more likely to experience other forms of trauma later in life, this compounding effect can be a risk factor in developing C-PTSD.

Another aspect of complex trauma is that it is usually caused by another person. The effects of it are more widespread than PTSD, where it may affect emotional regulation and beliefs about yourself. This is a response to consistently feeling unsafe and like you can’t escape the traumatic situation.

Complex PTSD Criteria vs. PTSD Criteria

Complex PTSD inherently meets all the same criteria as PTSD but further expands some criteria.

PTSD Core Areas

To meet the diagnosis, you must meet the three core areas of PTSD –
re-experiencing the traumatic event, avoidance of reminders or triggers of the traumatic event, and hypervigilance.

Re-experiencing can look like flashbacks of any kind, nightmares, or intrusive thoughts about the trauma.

Avoidance of reminders typically looks like anything to avoid triggering flashbacks or other unpleasant reminders of the trauma. It can look like avoiding people or places associated with trauma or trying not to think about traumatic events.

Hypervigilance is feeling on guard against an imminent threat of some kind. Sitting with your back against the wall, checking behind you frequently, or getting startled easily might be behaviors of hyper vigilance (the ICD-11 notes that individuals with C-PTSD might be startled less easily than traditional PTSD). Other behaviors can be things you picked up from your trauma that you learned to keep yourself safe (e.g., hiding food you’re throwing away because something bad used to happen if you didn’t, etc.).

Sometimes the primary symptoms of PTSD can look more subtle with C-PTSD because you learn to diminish them or were forced to express them covertly. For example, some ways my re-experiencing shows up is often emotional flashbacks where I may not be aware that I’m having a flashback. My avoidance tends to look like avoiding conflict or saying yes when I don’t mean it to try to appease since conflict is a trauma trigger for me. Hypervigilance for me tends to be somatic symptoms like the inability to relax and tension in my shoulders from my body overreacting to minor stressors.

C-PTSD Criteria

Along with the core areas of PTSD, C-PTSD highlights three additional criteria. The criteria are quoted from the ICD-11.

A) Severe and pervasive problems in affect [emotional] regulation.

The examples the ICD-11 lists are greater emotional reactions to minor stressors, violent outbursts, reckless or self-destructive behavior, dissociative symptoms while stressed, and emotional numbing (particularly of positive emotions). I think that coping style can also indicate this. For example, using substances, food, or other distractions to emotionally numb or regulate shows issues in emotional regulation.

This one sounds lofty, but it’s universal for those that have experienced complex trauma. The example the ICD-11 lists is an individual feeling guilty for not escaping the trauma or being unable to save others from experiencing it.

CW: Specific beliefs surrounding trauma

Here are some other examples of beliefs that could reflect this criterion:

  • I will never be in control of myself or my emotions.
  • I should have done more. I’m partially to blame for not doing more to stop it.
  • I’m a terrible person.
  • I shouldn’t have kids because I know I’ll abuse them.
  • I will always be tainted by my abusers.
  • People know I’m different because of the trauma.
  • I will never be healed.
  • I am a broken or damaged human.
  • I deserved the trauma because of something I did.
  • It’s not worth trusting other people because, in the end, I know they’ll hurt me.
  • I cannot trust myself.
  • Others can’t hear what happened. They’ll look down on me or see me as broken.
  • I’m crazy or out of control.
  • Why does it matter if I do self-destructive actions?
  • I’m not worth protecting.
  • My abusers stole a piece of me that I can never get back.
  • If people knew the real me, they’d stay away.

Many more beliefs can be associated with this criterion that isn’t listed here, and you don’t need to have every belief to meet the standard.

It may be difficult to examine your beliefs for many individuals, especially those with interoception difficulties. It may be easier to examine behaviors. For example, if you believe “I will never be in control of myself or my emotions.” you may check your behavior often, prevent yourself from connecting with others, isolate yourself when you have large emotions, or avoid seeing therapists because you don’t believe they’ll help. Think of corresponding behaviors to the beliefs above and see if you meet the criteria.

Another note I wanted to add here is that I’m not placing value judgments on the beliefs above. Many professionals refer to these as “negative beliefs,” which only serve to further the shame around them and can gaslight survivors. Feeling like others are not trustworthy may be a rational belief in response to a scary circumstance. It’s important not to dismiss this as irrational but instead recognize how the belief affects your functioning in the here and now.

C) Persistent difficulties in sustaining relationships and in feeling close to others.

The example cited in the ICD-11 is that the person avoids, insults, or has little interest in social relationships. Or, they have intense relationships that don’t last very long.

Autism complicates this a bit because it becomes an issue of “am I not wanting to engage socially because of autism, c-PTSD, or both?”

I think there are some key distinctions here. The criteria for autism mention difficulty with social communication. It does not specify avoiding or having little interest in social situations. It can be a learned behavior for autistic folks due to compounded trauma in social situations to avoid them. Whether social trauma alone is enough to meet the criteria for complex trauma is debatable and out of the scope of this article, but depending on who’s defining it may or may not fit the definition.

For this criterion, it’s essential to examine your own relationships. How many people are you connected to? How long do your social and romantic relationships tend to last? How many close friends vs. acquaintances do you have? Do others feel like you’re distant, clingy, or inconsistent?

This goes back to attachment style. You likely meet this criterion if you identify with an insecure attachment style.


One of the most contentious parts of this diagnosis is how it’s differentiated from borderline personality disorder (BPD).

Various studies have explored markers to distinguish the two, but one from 2014 discussed four major symptoms that set it apart. Four symptoms that indicate BPD over C-PTSD were 1) Frantic efforts to avoid abandonment, 2) splitting (switching back and forth from seeing another person as all good or all bad), 3) unstable self-image, and 4) impulsiveness.

There are a few important considerations with this. First, many of these symptoms are developmentally dependent. A teenager or young adult is expected to have an unstable sense of self and impulsiveness. A fully formed adult brain is not. Considering this is important for whether someone meets diagnostic criteria.

Second, differential diagnoses must be considered. Since dissociation is present in both c-PTSD and BPD, an unstable sense of self can indicate a dissociative disorder instead of BPD. Impulsiveness is a feature of many clinical diagnoses, including bipolar and other personality disorders. Another common misdiagnosis of BPD is rigid thinking in autism (ASD) or obsessive-compulsive (OCD) being mistaken for splitting.

Third, a person can have both BPD and c-PTSD. This can be especially difficult to differentiate since there is symptom overlap between the two. Another problem with not having c-PTSD in the DSM is that it would be difficult for a clinician to correctly attribute which symptoms are associated with which diagnosis since PTSD does not break down the criteria in this way.

Not having c-PTSD in the DSM creates a conflict between accessing formal evaluation that can differentiate these diagnoses and not having adequate language in the diagnostic criteria to do so.

A note on healing

Meeting the criteria of c-PTSD does not mean you are doomed forever and that your life is fated to be unstable or unfulfilling. C-PTSD is a trauma disorder. Trauma can be healed, and your symptoms can go away with time, therapy, and self-exploration.

I used to meet the criteria for c-PTSD. Now, my symptoms would be considered in remission. If you had asked me years ago if I would ever get better, I likely would have told you that c-PTSD is incurable. That I was going to be miserable and unstable for the rest of my life with little hope of connecting with others.

Learning coping skills that work for me and having words for my experiences, connecting with unconditionally loving people, and finding a therapist I developed a deep rapport were all essential parts of my healing. Finding ways to contribute to my community through mutual aid and writing my story were powerful ways of reclaiming a past I considered broken.

Trauma changes your brain and so does healing.” – Dr. Jen Wolkin

Blog Update: Why I Suck At This (And That’s Okay)

Hello everyone! I know at least a few of you read my blog regularly, so I felt it was important to be transparent with where I’m at.

To be honest, I’m struggling with this blog. I’m doing well in other areas of my life, but I’ve hit a re-evaluation period now that we’re heading toward the end of the year.

TL;DR I started grad school this year, and it’s taken all my time. I cannot promise any consistency anymore and will likely write when I want to. I will also let the blog default to at the beginning of 2023, so expect that change soon. The resources will still be here. I don’t intend to take the site down.

Motivation and Time

I love this blog. It has become part of my identity over this last year because it represents a lot of my current theories and sums up support resources. It makes it easier to help people because I can link articles. It’s given me a more flush outlet to express myself. I’m glad that I made this.

But who could have guessed that a blog about my mental health would ultimately be affected by my mental health?

I’ve wanted to create post consistency, but I’ve had the struggle of every blog creator. I don’t have the energy or ideas to create content every week. That makes posting content every week impossible. On top of that, when the demands of life are too great, this is one of the first things I drop. I want to dedicate time and often spend countless hours creating well-researched articles.

I take pride in what I post here. I’ll have around 30 articles on this blog by the end of the year. That’s no small feat. I have to prioritize other things right now, so my efforts moving forward will be limited.


It turns out that blogs don’t work like Tik Tok. They’re much more difficult. One popular post doesn’t translate to a significantly increased following. It certainly helps, but on Tik Tok, that’s where most of my audience came from.

I started this platform to get away from Tik Tok. Creating content on Tik Tok is not good for me, but it seems it’s the only way I get traffic here. I have much more to offer here than on Tik Tok. I get the nuance, direct links to resources, and more thoughtful engagement.

I have a lot of respect for my friends that have created content and succeeded. I also commiserate with my many friends who are like me that have tried to build a platform but are continuing to struggle to build an audience.


Another thing I’m struggling with is that I’m 22. I know a lot of my opinions are likely wrong. I know I’ll change my mind and have to eat my words later. My professional career may be impacted by being too open with my opinions.

I have blind spots I don’t know about. I try my best to stay informed and research topics, but I know I’m missing crucial aspects that I’m unaware of.

I don’t want to be just another mental health advocate that inadvertently causes harm with my platform. I’ve seen damage where advocates have lacked intersectionality and spoken for communities they don’t understand. When listening to voices harmed by other (much larger) advocates, I worry about how my platform may affect others.

I haven’t been accused of anything specifically, but I hope others feel comfortable discussing where I may be overstepping. I try to only speak from my experience where possible, but sometimes that comes off as recommendations for others.

The Future

So, what does this mean for the future of my platform?

I posted a Tik Tok about how they’re threatening to take down my account. I don’t think it will get taken down for now, but it’s always an underlying threat with that platform. If it ever does, I know I won’t re-join.

I plan on leaving this blog up. It will default to

I really appreciate everyone that follows me. I have made several friends through my platform, and many have told me they have been helped. I love that I was able to help even one person.

It’s interesting how much a task changes when it becomes an obligation over a passion. So far, this blog has become an obligation that I cannot keep up at the pace I’ve set. My focus moving forward will be to create content as I want, when I want, without any schedule. I anticipate this may kill my audience, but I don’t have the spoons to be an “influencer.”

I know this isn’t a typical blog post, but I appreciate it if you’re interested in where I’m going from here. I’ll try to keep everyone updated. I appreciate you giving me your time and your support.

7 Common Ways ABA Therapists Justify Unethical Practice

To listen to this topic, check out this podcast.

I remember getting into an argument with a Board Certified Behavior Analyst (BCBA) about planned ignoring online.

I argued that planned ignoring is unethical because it requires the therapist to withhold attention to gain compliance, which doesn’t address the underlying emotions driving them to seek that attention. It is inherently manipulative.

They replied with the one tactic that is my biggest pet peeve, almost universal among BCBAs that haven’t deconstructed and examined their practice.

She said, “it’s not withholding attention to gain compliance, it’s using differential reinforcement to reinforce appropriate attention-seeking behavior.”

She said the same thing I did in nicer, fancier words.

I’ve encountered this again and again. When Applied Behavior Analysis (ABA) therapists feel cornered, they often use ABA jargon to try to escape the moral dissonance. They usually assume that their opponent doesn’t know ABA terms and will agree with them when they explain it in the “correct language.”

And they’re right. Typically the people they’re arguing with don’t know ABA terms. This gives them the upper hand by placing it in a language outside the average person’s knowledge.

It also allows them to disengage. In fact, it’s a pervasive form of moral disengagement throughout our lives and is called euphemistic labeling.

Bandura’s Moral Disengagement Theory

Euphemistic labeling is just one of 7 tactics that Albert Bandura, famously known for social learning theory, came up with to describe how humans justify committing morally abhorrent actions.

His theory was devised to help explain how mass genocides and other similar actions happen. However, he specifies it can be applied to any action where we are distancing ourselves from moral dissonance.

Moral disengagement results in harm to others as a result of your actions. That’s why it’s absolutely critical ABA practitioners examine their own moral disengagement and challenge why they are engaging in those behaviors.

Notice your gut reactions to the examples below. If you find yourself wanting to defend them, you may want to critically examine your own defenses.

1. Moral Justification

The easiest way to understand moral justification is “the ends justify the means.” The reasoning is that since the immoral action has the purpose of helping the individual or surrounding individuals, it’s justified.

Having experienced unethical ABA, I saw this frequently.

The important thing to remember with these examples is that most harm in therapy is avoidable, and therapists have a moral responsibility to use tactics that do not cause damaging effects. This may include referring a client out, using a less restrictive or aversive treatment, or considering a multi-modal approach that regards the client’s level of distress and the long-term effects.

Some examples of this I’ve seen are:

“We had to use aversives to stop extreme maladaptive behaviors like self-harm and aggression.”

“It’s expected he’ll go through an extinction burst right at the beginning. It’s okay that he has more meltdowns because he’ll be better off in the long run.”

“They can communicate now! We gave them that. It couldn’t have been all that bad if they can now express themselves.”

Can you think of any examples you’ve seen in others? What about in your own practice?

2. Euphemistic Labeling

Euphemistic labeling is renaming an action to make it more palatable.

The example in the intro is one. Some others I’ve seen are:

Pairing is not love bombing. We shower the kids in reinforcement to pair us as the reinforcer and place demands the kid already knows. Later we withhold reinforcement for new behavior after the kid sees us as a reinforcer.”

“It’s not restraint. It’s a tight hug or holding a child.” (I’m not exaggerating, I’ve heard this one)

“ABA isn’t punishment-focused anymore. Instead, we increase the value of reinforcers by withholding the item until the appropriate behavior is displayed. It’s rewards focused.”

The knee-jerk reaction to hearing terms such as love-bombing, manipulation, or abuse is to recoil. No one wants to think of themselves as manipulative, especially when they aim to help children.

That doesn’t mean that manipulative actions can’t happen under the guise of science. After all, there are plenty of examples in the scientific community of harmful actions presented in sanitized language.

A helpful exercise is to break down what you’re doing in plain language without using ABA terms. Put it in terms like you were seeing a cognitive therapist. Would you be comfortable in a therapy session where your therapist did the action you’re doing? What if a teacher did this at school to your child?

Another good test is whether you would be comfortable with your action being published for others to read. What if it was by published by an autistic advocate and not a colleague?

3. Advantageous Comparision

An advantageous comparison is comparing one action to a worse action to make it seem better. Countries often do this to justify wars – we’re saving the people by intervening; it’s much better than the horrible state they currently live in.

Some examples of how this shows up in ABA:

“ABA was horrible in the past. It’s much better now.”

“ABA isn’t abuse. It’s not like we’re hitting kids or screaming at them.”

“Her last center just let her go the whole day without feeding her. This is much better!”

“Sure, most BCBA programs don’t have an autism education course, but therapists are allowed to assess mental health conditions after only one class.”

Just because the actions are being compared to a worse or equivalent scenario doesn’t mean current interventions aren’t harming the individual.

4. Displacement of Responsibility

This fallacy is better known as an appeal to authority. The person claims they were “just following orders” to create distance from their actions. The infamous Milgram experiment comes to mind.

This is especially prevalent for Registered Behavior Technicians (RBTs), whose whole job is to follow the plan set out by the BCBA. What happens when that BCBA creates an unethical plan?

This can also look like appealing to the directions of the clinical director. Overloaded case load preventing ethical treatment? No worries, it’s the fault of the clinical director, not the BCBA. /s

“I’m just following the directions of the BCBA/clinical director.”

“I’m just acting in accordance with the BACB standards of practice. If they say that what I’m doing is ethical, it must be.”

5. Diffusion of Responsibility

Diffusion of responsibility takes the displacement of responsibility to a new level. It means blaming the group to absolve the individual. So, no single individual is held accountable when the foundation, the organization, or the field is responsible for unethical actions.

This is seen prominently with the well-beaten drum of “Not all ABA.” Almost anywhere you go where there is critical information about ABA, an ABA practitioner pops up like you said Bloody Mary three times in a mirror to comment that their practice is different.

When you say “our practice is different” what is the goal? Are you putting distance between yourself and the perceived bad ABA? It stops you from considering how your own practice may have similarities.

Let’s assume you run the field’s most ethical, gold-standard practice. Who then is responsible for closing unethical clinics down? Is it the BACB? The clinical director?

Indeed, the clinical director believes what they’re doing is right, and the BACB isn’t going to do anything if no one is holding that clinic accountable. Your reaction shouldn’t be to tell someone you’re not like that. It should be to hold those clinics accountable.

You cannot claim your field is ethical if you allow unethical practices to exist by distancing yourself.

Judge Rotenburg Center (JRC) is an excellent example of this. Every ABA practitioner must hold them accountable by removing membership in organizations that support them (like ABA-I), mass reporting to the BACB, and joining legislative bans against torture.

Yet, many ABA practitioners are set on saying “not my practice” or “that’s an exception” when electric shocks are brought up as modern use of punishment in ABA.

“Where everyone is responsible, no one is really responsible.” – Bandura.

6. Disregarding or Misrepresenting Injurious Consequences

This title is pretty self-explanatory. This is when individuals minimize or ignore the harm their actions have caused.

This is very common when behaviorists disregard the real harms that individuals that went through ABA say they experienced.

The field exclusively focusing on quantitative data on vulnerable children, refusing to study autistic perspectives (until recently undertaken by autistic researchers), and omitting potential adverse outcomes shows this blatant disregard of harm.

One tactic is using a broad brush to paint those against ABA as “histrionics,” exaggerating, or misinformed.

Another approach is tone policing. Tone policing is when a person or group in a position of power (in this case, autism therapists) critiques the way something is said by a person who is not in power (in this case, autistic people) instead of engaging with the content that is being delivered.

ABA is the product of many systemic issues, so tone policing is a weapon to silence those with less power. If an autistic person is too direct (what, autistic people are direct?) with their hatred of ABA, if they don’t know the correct terms, or if they display emotionality, they are often dismissed as radical, reactionary, or the “anti-ABA crowd.”

How do you feel when you hear about “the anti-ABA movement”? Do you think they are overreacting? This is your call-in to examine that.

7. Dehumanization

Dehumanization sees the person as sub-human and/or deserving of a harmful action.

One of the most significant ways this shows up is the prevalence of ableist language in ABA. Things like functioning labels (calling clients low-functioning or high-functioning) or Asperger’s (specifically in the U.S. and other countries where this is no longer a diagnostic standard). Other ways ableist language exists is the use of the puzzle piece or participating in #lightitupblue, using terms like non-verbal in place of non-speaking, person-first language (person with autism) or “mental age” (i.e. they’re 30, but their “mental age” is 10).

Some therapists may read the above list and instinctually feel defensive of these practices. After all, many of the things I listed are common in medical/academic circles and among parents. Often the first people parents interact with after diagnosis are therapists, so the language follows suit.

This shows how fundamentally disconnected the ABA community is from the autistic community. The reason the language above is not preferred is that it causes dehumanization. Individually, some autistic folks prefer some of these terms, but the community has clear preferences. Language and the preference of the affected community matter.

Other ways this shows up is speaking about clients as if they aren’t present, denying internal experiences (not considering emotions or other motor/neurological conditions), and regarding autistic adults that can communicate as inherently different than autistic children.

This can also show up in ways of practice like emphasizing the importance of acting typical through goals like “appropriate play,” and not gaining the necessary education to understand autism and its associated conditions.

Avoiding dehumanization requires listening to autistic voices, not to defend your position but to understand where we are coming from.

Here are some diverse autistic creators to follow:

(disclaimer: I have not vetted everyone on these lists, this is a starting point)

How in your practice are you utilizing disengagement? If you can’t think of any, can you recall any your colleagues have used? What are the results of morally disengaging?

No, Neurotypicals Don’t Hate Autistic People – Examining Sasson et al. (2017)

There’s a clip floating around Tik Tok from Devon Price’s Unmasking Autism.

Sasson and colleagues (2017), for example, found that neurotypical people quickly and subconsciously identify that a stranger is Autistic, often within milliseconds of meeting them. They don’t realize that they’ve identified the person as Autistic, though; they just think the person is weird. Participants in the study were less interested in engaging in conversation with Autistic people and liked them less than non-Autistics, all based on the brief moment of social data. It’s also important to point out that the Autistic people in the study didn’t do anything “wrong”; their behavior was perfectly socially appropriate, as was the content of their speech. Thought they tried their damnedest to present as neurotypical, their performance had some key tells, and was just slightly “off,” and they were disliked because of it.

Unmasking Autism, pg 185

It’s a powerful clip. I remember hearing Dr. Price’s words echo as I walked away from another social interaction feeling awkward and defeated. This clip out of context really negatively affected me. And it wasn’t long before I saw others on Tik Tok post about how their mental health suffered hearing that.

For many, it seemed like a no-win scenario. If allistic people viewed my behavior as automatically less comfortable to be around, what hope did I have when socializing? My social interactions suffered under this self-fulfilling prophecy. I saw myself as unable to interact with others, which made my interactions worse.

Dr. Price’s suggestion to this was the follow-up study by Sasson and Morrison (2019), where disclosure of the person being autistic improved social outcomes. This leaves a bit of a predicament. For those that do not want to disclose their autism, are they then doomed to be seen as less likable than their peers? What about undiagnosed autistic folks? Do these findings generalize to those with comorbid intellectual disabilities?

I want to preface this article because this is not a direct critique of Unmasking Autism. There are a lot of valuable pieces of advice and information in that book. However, this addresses the combination of factors that led to the idea that neurotypical people hate undisclosed autistic people. Dr. Price’s book does not conclude this, but it has been taken out of context to imply this.

This conclusion has been drawn partly because Dr. Price is a compelling writer who wrote this conclusively without addressing limitations. Part of it is how the studies themselves have presented the evidence. And the most significant contributor is how Tik Tok can spread (mis)information so quickly.

This is common for interpretations of autism studies both on Tik Tok and other media sources. Autism is political in the sciences and as a consequence gets summarized in non-scientific language that may not convey the complete picture of how a study was conducted.

So, let’s break down why we need to take the studies about neurotypical perceptions with a massive grain of salt.

Neurotypical Peers are Less Willing to Interact with Those with Autism based on Thin Slice Judgments

Sasson and colleagues ran three independent experiments, published together in 2017. Different methodologies were used to attempt to generalize the findings along with “natural” interactions of autistic adults and children with researchers. All ASD stimulus participants were “intellectually capable,” according to the study.

Experiment 1

The first experiment videotaped 20 autistic adults and 20 “typically developed” adults performing a mock audition for a game show. 214 typically developed undergraduate students then rated the participants on whether they were smart, trustworthy, dominant, awkward, attractive, and likable. They also had “intention” measures of whether the rater would live near the person taped, hang out with, sit next to, and talk to them.

They separated the format that the undergraduate raters watched by transcript, audio-visual, audio only, silent video, and static frame (pictures from the clips). They found that autistic people were rated less favorably in all measures except in trustworthiness, intelligence, and living near (though sitting next to them was also close).

This experiment seems compelling, but there are some key factors that we need to consider here as far as limitations. The first significant factor is that the raters were undergraduate students. It didn’t specify what the undergraduate students majored in, but considering that most recruitment happens through psychology and similar fields, it was most likely that.

This is a huge issue. This doesn’t mean that neurotypical people view autistic people as less likable. It means that a sample of undergraduate students saw autistic people as less likable.

Another issue (which the author acknowledges in limitations) is that the participants were videotaped. This doesn’t translate to real-life social interaction. And this likely had to do (particularly with static frames) with facial features and other atypical physical characteristics of autism, not with social interaction.

Even though the sample size was adequate, the sample itself was flawed and can’t be generalized. The stimulus was also limited. It’s hard to know if the twenty people in the sample were viewed negatively because of autism or if other variables could explain the difference in ratings.

For example, it’s well documented that physical attractiveness affects rater perception. While audio-only and speech content could mitigate this bias, this effect could have greatly affected the other measures. We don’t know anything about the stimulus participants except their diagnosis (or lack thereof). There are too many variables here to conclusively say that autism was why the stimuli were rated poorly, even if there was an association between autism and rating.

Experiment 2

The second experiment took 12 autistic adults (2 female, 10 male) and 17 typically developed adults (7 female, 9 male) that had to have a conversation with the experimenter about open-ended get-to-know-you type questions (like “Have you seen any good movies lately?”. They were filmed in POV style with a program that took 10 random pictures through the interaction (excluding blurry photos, etc.).

37 undergraduate students that received credit from participating then rated the frames on measures of “how awkward,” “how approachable,” and “how likely to be friends.” Participants were matched by gender, which is concerning considering there were only 2 autistic female stimuli. The raters were shown multiple clips of the same individuals to test if impressions shifted with repeated exposure.

Raters responded more favorably to the three measures to typically developed individuals, regardless of how often they saw an individual.

Again, these were undergraduate students. We’re examining one sample of undergraduates from one university. They received credit, so we can also presume they were in social sciences. This cannot be generalized.

The researchers acknowledged that repeated exposure does not translate to familiarity. So, knowing someone better may improve scores even if seeing pictures of the same individual didn’t produce a more favorable score.

The problem of visual perception affecting trait rating was especially relevant for this experiment. Again, they didn’t give us any info about the stimuli other than diagnosis, so we have no idea how much physical presentation and related factors played into trait rating. Pictures of interactions do not provide much social information, so concluding that this was evidence of autistic people being rated poorly for social cues is not accurate.

It makes me wonder if we arbitrarily grouped neurotypical people into two groups, would we see similar effects? In other words, how much are individual differences affecting these ratings?

Experiment 3

The third experiment consisted of 7 autistic boys and 7 typically developed boys as the stimuli. For this experiment, they had 98 adults and 33 typically developed teens as the raters. The ages of the adults were 19-64, and the teens were 10-16.

Stimulus participants were recorded telling a story of happiness, fear, surprise, and anger. One sentence was taken from those videos where all four emotions were expressed. The boys were rated as likely to start a conversation, have many friends, get along well with others, spend time alone, and have awkwardness. The autistic participants were rated less favorably on all measures by both adults and teens (though not significant on awkwardness for teens).

This sample actually had enough diversity to be decent. The teen sample was not large, but it was recruited through a large sampling database.

I think it’s interesting that they said that autistic individuals were rated less favorably on “spending time alone” (meaning they were seen as spending more time alone). I think that shows a bit of researcher bias as it was implied that this trait was perceived as a negative social trait.

The stimulus sample was the smallest of the three experiments, so individual differences could have played into judgments, similar to the other experiments. The content of speech would have also been very relevant, but the researcher didn’t provide any examples. Also, all stimuli were boys, so this can’t draw any conclusions about how young autistic girls are perceived.

This experiment had some flaws, but less than the other two. Overall, I think this was the best conducted of the three.

Problems with the researcher’s conclusion

One of the factors that went into how Dr. Price wrote their excerpt essentially had to do with how the study was presented.

The researchers presented all three experiments to conclude that neurotypicals create negative first impressions of autistic people, as demonstrated by the various methodologies and samples.

It seems like by using the three studies in conjunction, they were hoping that the limitations of each would be mediated by similar findings in another study.

Considering similar limitations existed for all three (limited stimuli and heavy reliance on visual presentation), and undergraduate students were the raters in the first two studies, concluding that the evidence is “strong” that neurotypical peers view autistic social presentation negatively is not substantiated.

My issues with this conclusion are validated by a follow-up study that Morrison et al. (2019) did that found rater association with autism affected the rating more than traits of the autistic stimuli.

Follow-up study questions their conclusion

The same 20 autistic adult videos from experiment one were used with 505 undergraduate raters. The undergraduate raters were given a series of traits assessments that measured their level of connection to autistic individuals and willingness to interact with autistic individuals the raters had.

They found that among this sample, the higher stigma of autism significantly predicted negative ratings of the videos of autistic participants on all measures except dominance. More stigma was also associated with higher negative ratings when the videos were labeled as autistic.

So, disclosing an autistic diagnosis may only produce a positive outcome if the person the autistic person interacts with doesn’t hold a stigma against the condition. I’m sure this is not surprising to most autistic people, as I do not disclose my diagnosis in every situation (for good reason).

Meanwhile, higher autism knowledge only produced more favorable outcomes when an autism diagnosis was disclosed.

Limitations of this study were the undergraduate sample and not including typically developed videos, so it’s hard to make a direct comparison.


There are many studies to consider when examining how neurotypicals feel when interacting with autistic individuals. There are more studies cited in Dr. Price’s book that I don’t have time to examine in one article. Since the focus is on Sasson et al. (2017) in the video circulating Tik Tok, I felt it was important to break down that particular study.

I also think it is unfair to Dr. Price to take a couple paragraphs from a 300-page book and pick apart the wording of it. That is why this isn’t a review of Unmasking Autism. This directly criticizes this excerpt’s use and the greater trend of misconstruing science in media.

I hope you leave this article feeling slightly less fatalistic about how autism affects your interactions, knowing that the study cited doesn’t apply to all autistic people. It also affirms (and what I think Dr. Price’s greater point was) that autism education is essential to help improve communication between neurotypical people and autistic people.

I Want to Leave ABA – Alternative Careers for RBTs and BCBAs

  1. Where can I work if I only have my HS diploma?
  2. What can I do with an associate’s?
    1. Associate’s in a specialty:
    2. Associate’s in a general field:
  3. Bachelor’s Degree

I cringe when I see ads from my college to join their ABA clinic. I see the appeal. They market it as a way for psychology (and related majors) to get experience in their interested field without a bachelor’s degree. That’s very attractive considering that most psychology jobs require a master’s to practice.

It appeals to the desire to help others and advance your career. “Help these poor children with autism have a better life and gain experience in your field!”

They don’t mention how they can pay you less because you don’t have a college degree. They don’t mention the controversy surrounding ABA or how underprepared most RBTs are because of their level of education and experience.

I get the appeal. It’s the whole reason I was in ABA in the first place. I wanted to work in my field and help people. I didn’t know anything about autism beforehand and ABA was sold to me as this novel way of improving people’s lives. I was young, naive, and my labor was exploited as a consequence.

One of the most common questions I get is, “I want to leave ABA, but I don’t know where to go. How do I get experience in my field?”

It’s a question that I also struggled with when leaving ABA. It seemed like I was walking away from a golden opportunity to be prepared when I entered graduate school and my career.

I regret how long I stayed in ABA. The longer I stayed, the more unethical situations I encountered, and the worse my burnout became. In the moment I couldn’t see anything except how much I’d be missing out on by leaving. I didn’t realize how many opportunities exist for working in my field without a degree that doesn’t require me to work against my values.

Where can I work if I only have my HS diploma?

If you’re in a similar situation, you have a high school diploma as it’s required to work as an RBT. So, let’s start there.

  • Mentoring (avg. $16.24 /hr) – the first job I took after leaving was a mentoring position. These positions typically involve working with youth and providing support, academic guidance, or chaperoning. If working with students with disabilities is your passion, you may look into your college’s disability center, schools in your area, or youth camps.

  • Special needs nanny (avg. $21 /hr) – often parents of kids with disabilities have difficulty finding reliable individuals to babysit or watch their kids. Nannying can pay well, especially if you’re required to have a more intensive care role. This will allow you to bond with a disabled child without the pressure of practicing any type of therapy.

  • Direct support staff (avg. $15.23 /hr) – direct support staff work in-home or at a center dedicated to treating individuals with disabilities. I recommend this with caution. Many direct support places for individuals with disabilities have inhuman treatment and services. Many can be equal to or worse situations to work in than ABA clinics. And many undertrain their staff, the work is intensive, and they don’t put in enough safety protocols to maintain wellbeing. That being said – if you can find a reputable company that treats their employees well, this can give you experience working with individuals with disabilities and be meaningful work. Edit – I was informed by a reader that direct support staff are sometimes trained using ABA materials and techniques. Keep this in mind when looking for companies.
  • Respite staff/personal care attendant (avg. $12.75/hr) – respite staff work one on one with clients with disabilities and usually help in the home with care tasks, recreation, and other needed tasks. This is similar to direct support staff in both type of work and job risks (emotionally and physically demanding, with many exploitative companies), but the work can be very rewarding and allows you to get to know an individual better than a group home where you would typically be in charge of multiple people.
  • Rehabilitation aide (avg. $15.71 /hr) – rehab aides help physical therapists with patient care and miscellaneous office tasks.

  • Research assistant (avg. $20.8 /hr) – research assistants help perform research of all types. A psychology research aide may help conduct research, analyze, or prepare manuscripts.

  • Tutoring (avg. $18.31 /hr) – tutoring is another great direct support role with kids. There are centers dedicated to special education, usually focused on reading and writing.

  • Social services (social work) assistant (avg. $19 /hr) – social services assistants provide general support for patients in clinical settings. This can include helping fill out paperwork, coordinating care, or other office tasks. While only a high school degree is required, some companies require an associate’s or higher degree.

  • Accessibility staff (avg. $17 /hr) – this has different names depending on where you work, but accessibility staff provides support for people with disabilities in businesses or other locations. For example, if you are an accessibility staff at a college, you may be in charge of reading tests or assignments, taking notes, and talking to professors to get support for your client. Look into accessibility services at whatever location you’re interested in working in.

  • Paraprofessional (avg. $15 /hr) – paras help students with disabilities in the classroom and during other activities during the day. You may have some teaching responsibilities, but most of your duties will be assisting students with their needs and helping with academics. Some paras do provide ABA. It depends on the school, district, and special education classroom that you work in.

  • After-school teaching or teaching assistant (avg. $14.5 /hr) – teaching generally requires an advanced degree, but teaching after-school or summer programs typically doesn’t. This can be a great flexible part-time job, especially if you’re pursuing school. Teaching assistants have similar flexibility but have much more to do with assisting the professor or teacher in their tasks than directly interacting with students. Teaching assistants for special education will generally involve more direct interaction.

  • Case manager assistant (avg. $23 /hr) – case management assistants work under the guidance of a case manager and will often meet with clients to find out their unique needs. They will often locate resources, contact providers, advocate for clients, and support the needs of the case manager.

  • Crisis line worker (avg. $21 /hr) – if you can handle the stress of a job like this, crisis lines can be a meaningful way of helping people in the community. Crisis line workers typically answer calls of people experiencing mental health crises and talk with them to help de-escalate the situation.
  • Volunteer – this may not be the most feasible option depending on your situation, but it can be a great way to build experience in your chosen field. Because you are giving your time, generally, there are not a lot of barriers to becoming a volunteer, and as long as you follow the organization’s rules, you don’t have to worry about being “fired.” This can be part-time while you work in an unrelated field and act as a springboard into a more permanent position.

Read on for information about what associates you can get to pursue a long-term career.

What can I do with an associate’s?

There are not many human services careers you can do with an associate’s that you can’t do without one. There are two sections here I want to talk about. If you don’t already have an associate’s, there are some specialties you can get one in that can become full-time careers. If you already have an associate’s, there is also an option for you.

Associate’s in a specialty:

  • Occupational therapy assistant (avg. $30 /hr)- if you go through an occupational therapy assistant program, you can help implement an OTs plan for a client. This is similar to an RBT in that you are implementing therapy, however, you have two years of schooling specifically about the profession to help aid you in the best and ethical choices. OT assistants work in a variety of settings, similar to an OT.

  • Speech-language pathology assistant (avg. $24.5 /hr) – similar to occupational therapy assistants, SLPAs implement speech therapy under the direction of an SLP.

Associate’s in a general field:

  • Mental health or psychiatric technician (avg. $17 /hr) – mental health technicians oversee patient care and administer. There are four levels, with the higher the level allowing for more specialization. Level 1 requires a high school diploma, 2 requires 480 hours of college, level 3 requires 960 hours, and level 4 requires a bachelor’s degree. Some mental health/psychiatric tech jobs require certification courses.

Bachelor’s Degree

With a bachelor’s degree, you gain access to many more careers in psychology.

  • Mental health rehabilitation specialist (avg. $22 /hr) – MH rehab specialists work with people experiencing difficulty with their mental health and help people learn how to cope and manage their illness.

  • Case manager (avg. $20 /hr) – case managers are responsible for managing cases for individuals with disabilities. They connect people to services, organize accessibility support and ensure that their care is optimal.

  • Child development specialist (avg. $20 /hr)- these specialists monitor and evaluate children’s development. Based on their evaluation, they work with parents and other providers to implement activities to support the child’s development.

  • Disability policy worker (avg. $23 /hr) – policy workers lobby for laws that support disabled people’s rights and advocate in the public sphere for better treatment of disabled people. While this has less of a caregiver position, it can be a good way of making a societal change to improve the lives of disabled people.

  • Psychological stress (polygraph) evaluator (avg. $28 /hr)- a psychological stress evaluator monitors and administers polygraph tests to indicate the truthfulness of statements.

  • Victim’s advocate (avg. $18 /hr) – advocates help victims after a crime has happened and will help connect the person with community resources. They can be a source of emotional support for victims and often provide various help, including legal support, intervention with employers, and submitting applications for government help.

  • Partial care worker (avg. $17 /hr) – partial care workers typically operate out of live-in facilities, help provide outpatient groups, support the facility’s scheduled activities, provide care and advocate for patients.

  • Teacher (avg. $26 /hr) – even if you didn’t get your degree in education, most places allow teachers to obtain a provisional license with any bachelor’s degree, provided you can pass the exam. Look up your area’s requirements for teaching licensure.

  • Social services specialist (avg. $20 /hr) – social services specialists interview families or individuals and determine risk, needs, and intervention scope. They arrange services, contact relevant agencies, and help arrange placements in facilities if needed. They may also help organize vocational help and other employment assistance. Many places allow you to work in this role with a bachelor’s degree and experience in the field, though some sites require a master’s degree.

Hopefully, this gives you an idea of some alternatives to working in ABA that allow you to still care for disabled people. If any of the information above is inaccurate or incomplete, please let me know so I can adjust. Or, if there are any careers I missed, feel free to add!

Acting Childish – What is Age Regression?

This post contains affiliate marketing links.

CW: This article references adult topics, including kink. Reader discretion is advised.

I received a notification from Tik Tok that my video had been taken down. It was my video on little alters.

I did a series showcasing different types of alters, and for each video, I dressed and acted like the type of alter in the video while providing helpful information.

So in the little video, I held stuffed animals, had a pacifier, and acted childishly. It got taken down for “adult nudity and sexual content.”

I was able to appeal and get the video restored, but I was not surprised at this reaction. When people see adults acting like children, they automatically think it’s related to pedophilia.

My entire life, I have been complimented for seeming mature and grown-up. Now that I’m an adult, I’m bombarded with the need to experience childhood. I needed a safe space to be cared for as a child.

Age regression is a complex topic that we don’t know a lot about. Science has almost no research on voluntary age regression, and the little that’s been explored has been on involuntary or hypnotic regression.

Social media has shed light on age regression, showing a community of people coping similarly.

What is age regression?

Age regression is the voluntary or involuntary experience of reverting to a childlike state (little space); mentally, emotionally, and somatically. It is not a sexual experience but a coping mechanism for dealing with stress, particularly if the person has experienced childhood trauma.

Age regression is exhibited in many mental conditions, including anxiety, BPD, PTSD, DID, OSDD, autism, and more.

Involuntary age regression is often the result of trauma and may be a cognitive/primary sensory flashback. This may look like going temporarily mute, suddenly having a reduced vocabulary or higher pitch, being flooded with childhood memories or emotions, craving that a loved one “makes it better”, or any other behavior that is regressive to your usual state of being. This is done without a conscious effort or control over the reaction.

Conversely, voluntary age regression is an intentional state of regression that is a coping mechanism to de-stress and regulate.

In many ways, age regression is a form of self-hypnosis, where you enter a trance-like state to achieve mental relief.

There is a hypnotic therapy technique that involves a therapist initiating age regression but has been critiqued for its tie to false memory recovery. Voluntary age regression is different as it is not for memory recovery or necessarily done with a therapist.

Since there is not enough literature to conclude whether voluntary age regression is healthy, the subject remains controversial among therapists. Some worry that it is a state of avoidance to distract from difficult processing, whereas others believe it’s a healthy coping mechanism that allows the individual to return to homeostasis.

I agree with this second school of thought, where as long as it’s being practiced safely, I think there are health benefits.

Age phenomena

Age regression is a small piece of much broader “age phenomena.”

The one that age regression is most commonly compared to is age play. Age play is a sexual kink dynamic where two consenting adults usually pretend to be a child and caregiver. However, age play can be any age, and some will play out other dynamics involving being older than they are, etc.

Age play has a negative stigma because many view it as tied to pedophilia. Age play does not involve minors and is usually done for the power dynamic and level of care the “caregiver” provides the “little.”

This can be confusing compared to age regression because many littles in this dynamic describe “little space” as an age regressor would, where they are cognitively similar to the age they are roleplaying. The most significant difference is that age play is for sexual intent, whereas age regression is strictly not.

Another commonly confused term is “little alters.” Little alters are alters in a DID/OSDD system that is cognitively like children and often stuck in time. Littles do not regress, they are generally permanently that age. Regressors, however, revert back to the adult age they are when the session is over.

The last confusing term is age sliders. Age sliders are also unique to DID/OSDD systems, and they describe alters that are not a set age but switch ages depending on the circumstances. They may regress, but they stay that age cognitively until they decide to slide back. Some can also slide to be older than they are, so it flows in both directions.

While many of these terms are used interchangeably like “littles”, “little space”, “caregiver” and “regress”, context is important for determining the type of age phenomenon being discussed. Depending on whether discussing systems or non-systems, sexual or non-sexual, you can determine whether what is happening is age regression or something else.

Benefits of age regression

Age regression can be very beneficial for establishing a good relationship with a caregiver, engaging the parasympathetic nervous system to calm down, return to a state of homeostasis, and heal the neglected needs of your inner child. It can help process difficult emotions or as a form of temporary escape.

It can also be powerful in engaging play, which improves brain functioning, connection, and well-being. Especially when someone has experienced childhood trauma, play can become a foreign experience, and returning to a childlike state can help facilitate this.

How to safely age regress

I’ve mentioned safety several times in this article. What does age regressing in a safe way entail?

The most significant safety consideration is regressing alone vs. regressing with a partner (referred to as a caregiver in the age regression community). Regressing alone gives you more freedom to do whatever you need in the space and prevents harmful dynamics from forming. However, you lose out on the connection to a caregiver, and it can be harder to exit if you’re unfamiliar with your own triggers.

Regressing with a partner gives you the experience of being taken care of and can be a powerful bonding experience. Many adults are uncomfortable taking on this role, which may force someone to look online or in other public spaces for a caregiver. This is where safety really comes into question.

While most age-regression spaces forbid sexual content, many predators lurk on the forums looking for vulnerable individuals under the guise of non-sexual regression. That’s why it’s crucial to vet the person you want to regress with. I would highly discourage minors from looking for caregivers. For this reason, it’s much safer to regress by yourself. Never bring a non-family adult into your regression if you’re under 18.

Another safety concern is that you should not be in little space when interacting with children, as this violates the boundaries between adult/child relationships. Even if you may feel cognitively similar in the moment to the child, you have the brain and body of an adult. Little space should be achieved in your own time, in a designated environment.

As for regressing by yourself, a big part is letting go of feeling like you’re doing something wrong. Our society looks down on children, so people are critical when an adult desires to act childlike.

One of the most helpful ways of regressing is using kids’ toys and materials to help enter little space.

I set up my closet with a soft rug and rainbow lights. I replaced the door with a shower curtain and a comfy chair to give me the space to regress.

Some of the products that I would recommend:

Entering and Exiting Little Space

Something to watch for when trying little space is what takes you in and out of it. You should choose activities and items that will help you regress in a controlled manner and take you to a comfortable level. There’s no hard and fast rule on how to get there. You’ll just have to observe your own state as you regress. I’d recommend starting with items or activities you enjoyed doing as a child.

The other important part of regression is to have triggers to pull you out. That way, if there’s an emergency or an interaction you have to be an adult in, you can quickly come out of the headspace. After all, if you think of this as hypnosis, it would be very irresponsible of a hypnotist to leave you hypnotized without pulling you back out.

Some exit triggers could be entering a new room, engaging in a more complex task, having a ritual for putting away your little space stuff, setting a timer that signals the end of regression time, counting up from 10, or having a cool-down activity like playing with play-dough to re-gain your mental capacity if you have time.

Age regression can be an amazing tool for healing a wounded inner child and regulating the emotional demands of adult life. Understanding that age regression is a healthy, non-sexual coping mechanism can help fight the stigma against it.

DID Integration – Accepting My System’s Cohesion

My life was in pieces when I started therapy with my incredible therapist three years ago. I had a suicide attempt only two weeks prior. I was housing insecure, I had been unemployed for months following one of the worst psychological breakdowns I’d ever had, and I was still experiencing uncontrollable amnesic switching.

My therapist furiously took down everything that first session, letting me fill her in on my extensive trauma history. One of the initial green flags was that she stayed until I was done, which was thirty minutes past the session. She cared about me more than the “therapy hour” (45 min session) that all the previous therapists I had lived by.

It’s bittersweet writing this because I’m now in a place where I am stable, have achieved more than I ever thought I would, and have to say goodbye to someone that helped me change my life.

One of the things that amazed me about this therapist is that she had worked with clients with Dissociative Identity Disorder (DID) in the past. She knew exactly how to treat my symptoms and work with all of my alters.

It’s satisfying walking away from this relationship knowing that she helped me achieve integration, all while I was completely unaware it had happened.

What is integration?

Integration is often confused with many other terms by both clinicians and people with the condition.

The ISST-D cites Kluft (1993) for the definition of integration.

[Integration is the] ongoing process of undoing all aspects of dissociative dividedness that begins long before there is any reduction in the number or distinctness of the identities, persists through their fusion, and continues at a deeper level even after the identities have blended into one.

Kluft (1993)

Put simply, integration is alters working towards cohesiveness without dissociative or amnesic barriers.

Since integration is a process, there isn’t a distinct endpoint. Each person can decide where they are in that.

A term this is most commonly confused with is fusion. Fusion is when two or more alters fuse together to become a new identity made up of those identities. In many communities, the concept of fusion is compared to gem fusion in Steven Universe. I like this analogy best, but some systems feel that the SU analogy sensationalizes fusion.

The final form of this is called “final fusion.” This is when all alters fuse to become a singular identity. Final fusions aren’t recovery from DID as someone can un-fuse or split new alters during stress or trauma. All fusions have the potential to un-fuse later, but many don’t.

There aren’t any specific therapies to fuse. There hasn’t been any formalized process either. Most systems that experience fusion describe it as happening randomly and without control. It can be a scary experience and come with a sense of grief from losing distinct parts.

We haven’t had any fusions in our system. We all have bets on who’s most likely to fuse, though. 😉

Since fusion is a scary and unstable process, when it’s conflated with integration, it can give integration a bad reputation. Integration is one of the best-known treatments for DID and doesn’t necessarily involve any loss of identities.

Therapists work on reducing amnesic and dissociative symptoms and help the system work united. This typically involves identifying alters and their needs, coming up with solutions to meet those needs, building communication between alters, and confronting trauma in a safe environment as it organically comes up.

Many systems say they are against integration and for functional multiplicity. What is functional multiplicity?

It’s integration. Or at least integration without fusion. Functional multiplicity is alters working together with limited or absent amnesic or dissociative symptoms. It’s seen as affirming since the focus is not on trying to make alters an inseparable identity but instead to have all remain distinct and allied.

So much of the hate towards integration comes from a misunderstanding in literature and community language.

Why do we call our system integrated?

Why call our system integrated if integration is a process without an endpoint?

For us, saying we’re an “integrated system” is another way of saying we’ve achieved functional multiplicity. I like integrated over functional multiplicity because it better describes how our system acts as a whole. Our switches are so seamless now that while we are still separate, we function as if we weren’t most of the time.

Every system can choose to define their system the way that they want. We have no problem with someone using functional multiplicity to describe themselves.

It took a while to accept that we are integrated. It wasn’t a big event. There was no finite moment where we knew. It was a gradual process over years of therapy and working together.

When reflecting on our current levels of amnesia and dissociation, it became clear that it doesn’t happen often. We don’t experience amnesic switching anymore. Our dissociation is minimal and typically related to autism. We have some memories that aren’t accessible to the host but aren’t causing distress and will be recalled in their own time.

We are still on the path of integration. Memories will continue to arise, and we will definitely have lapses throughout our life. We hope to eventually achieve fusion. But we also have made incredible progress and can remain integrated through periods of high stress and instability.

Being integrated is so rewarding and allows all of us to live the lives we want while being ready for anything. We can use our alters’ strengths to face any challenge without losing time or being at odds.

If you believe you can’t achieve integration or functional multiplicity, we didn’t think we could either. Check out our system resources for help accomplishing this process.

Different Types of Flashbacks in PTSD and Complex Trauma

After a stressful event at work, I sat in the hall gasping for breath. I rationally knew what had happened. I had been yelled at, which triggered my PTSD. That didn’t stop my body from shaking and going through the panic of feeling helpless to save myself.

Talking about triggers in popular culture sounds like people being so sensitive to little events. You hear it thrown around as a buzzword and politicized as a way to diminish valid emotional reactions.

Trigger refers to an event or experience that reminds you of a traumatic event in your life. It brings up painful emotions.

Many years ago, I thought of triggers as their own PTSD symptoms, separate from flashbacks or other symptoms. Flashbacks were those “video clip” moments where your brain forces you to watch in vivid detail. That’s how they were described in all the resources I could find. I wasn’t familiar with complex trauma at the time.

Then I learned about emotional flashbacks. As the term implies, emotional flashbacks are emotion-focused flashbacks where you experience similar emotions to a traumatic period in time without necessarily getting clear images or somatic experiences.

While sitting in this hallway at work, I was having an emotional flashback triggered by the event. It was like being a child again, helpless and afraid. I likely would have regarded the situation as a panic attack a few years ago. But panic attacks aren’t tied to specific trauma triggers.

I tried looking into the different types of flashbacks further. If there were visual flashbacks and emotional flashbacks, were there other types?

The scientific literature didn’t have much to offer for variations on the “typical” flashback, reliving the moment in detail.

PTSD research has focused on single trauma cases, especially since, in the U.S., the DSM-V doesn’t have a classification for complex trauma. Often when going into a new therapy office, I have to indicate which trauma is my “worst trauma” since many of our therapy models rely on dealing with the singular root trauma. There isn’t room to see trauma as compounding, reducing trauma to very defined events of what can count as trauma.

Since practice falls behind research, it hasn’t caught up with the current understanding of things like minority stress, “social traumas,” or other complex traumas.

So, it’s not terribly surprising that research on types of flashbacks is nonexistent.

With all of that in mind, this is an article on a blog. I can try my best to provide a theory based on the current literature, but that theory is not scientific (yet).

To understand flashbacks, we need to understand the senses.

What are the senses anyway?

Oh! That’s an easy one. We learn this in kindergarten – eyes, ears, mouth, nose, and touch. Later on, we may have been exposed to other senses like vestibular (movement awareness) and proprioception (spatial awareness).

Often these are introduced as an accepted understanding of the world. The issue is that they’re phenomenological. And whenever you’re dealing with classification, it’s really tricky to say with any certainty that your classification system is an accurate representation of the world. As a consequence, a lot of the accepted “science” is a bit hazy, and mostly proposed theories with backing for some of the most major.

For example, Aristotle is credited to have first categorized the five senses. Other neurologists have identified and supported other systems. But depending on who you talk to there can be between 5-53+ senses.

This graph by New Scientist does a good job illustrating what senses are generally accepted in science. It also highlighted what “radical” senses have been proposed and a conservative understanding of the senses.

Graph showing conservative, radical, and accepted senses in science. Breaks senses into vision, hearing, smell, taste, touch, pain, mechanoreception, temperature, and interoceptors.

So, why does this matter to our discussion of flashbacks? Flashbacks are categorized by an individual’s somatic/sensory experiences, which requires a solid agreement on what senses count in that experience.

Flashback categories

CW: The following sections contain brief examples containing a variety of traumas.

A study compared flashbacks to regular auto-biographical memory. It found that flashbacks contained more visual, sensory, emotional, and other perceptual content than autobiographical memory. To people that have experienced traumatic flashbacks, this is far from surprising.

From examining the available literature and through my own experience, I’ve divided the types of flashbacks into Primary Sensory, Vestibular, Proprioceptive, Interoceptive/Emotional, Nociceptive, and Cognitive.

While these types of flashbacks may stand alone, most flashbacks are going to contain multiple types. The categories can be thought of as “Sense-Focused” flashbacks instead of as the only sensory experience of the flashback.

Primary sensory flashbacks

These flashbacks are what are most typically studied. They include the five senses as the focus.

The previously mentioned study found that visual information was the most common, followed by auditory for people experiencing flashbacks. Smell and taste were relatively rare. Touch falls under proprioceptive, so I’ll examine that more there.

Primary senses are the easiest to understand regarding flashbacks, so I won’t provide examples.


Vestibular-focused flashbacks are flashbacks that focus on the experience of movement. Motion can relate to the position and speed of you, people, or things around you.

Examples of vestibular-focused flashbacks may feel like hypervigilance, where you feel like your aggressor is following you. It may be like feeling the speed of a car coming at you, the feeling of body parts moving towards you, or your own body moving. It could also explain physiological descriptions of flashbacks like feeling dizzy, nauseous, off-balance, or like you’re falling.


Proprioceptors are nerve endings present throughout your whole body that identify things like touch, pressure, and your body in space.

Proprioceptive flashbacks may feel like someone or something touching you, like your body is present in that traumatic moment, weight on your body, or your skin crawling. It can also happen when someone touches you somewhere triggering, causing an acute sensation like being back in that moment.


Interoception is a wide array of internal experiences, including emotions, sense of time, and internal processes like blood pressure or hunger.

Primary emotions like fear, helplessness, etc., are more common in flashbacks than secondary emotions like guilt or anger.

Interoceptive flashbacks may feel like you’re experiencing the emotions from the trauma. In triggering your fight or flight, it may feel similar to the pounding heart and higher blood pressure you experienced at that moment. It commonly affects your sense of time, like moments are disconnected like a dream. Feeling like you’re in that time is also an interoceptive response.


Nociceptive is the system that senses pain. A study found that individuals who went through a traumatic event experienced pain after the event. They also experienced pain later when recalling the event.

Nociceptive flashbacks are characterized by pain in areas that may have been affected by the trauma or stress-related pain. It can appear unexplained and may be written off as “psychosomatic.” If you only started having pain following a traumatic event, it’s worth considering that the trauma likely affected your nociceptive system.

It could also relate to other descriptions of pain during a flashback, like feeling like you’re burning, shocked, or being pulled apart.


Cognitive flashbacks are not a sensation so much as a pattern of behavior. A CBT therapist might tell you to examine cognitive distortions after a traumatic event, like feeling like people are out to get you, etc.

I think it is worth considering that this is a type of flashback. You may have distinct thoughts and related behaviors that you experienced during the trauma. It may also describe compulsive actions like trauma re-enactment, which may result in thinking you’re gaining control or can prevent the trauma.

Cognitive flashbacks may also affect your mental understanding of a situation like you’re back in the trauma or thoughts like “I deserve this.”

How autism interacts with trauma

With all the different systems involved in flashbacks, it’s important to note that autistic people have a much higher likelihood of over 40% (this varies greatly across samples, but all agree that it’s much higher than the gen pop) vs. 4% in the general population to have probable PTSD.

The reasons for this are unclear, but it’s theorized that autistic individuals encounter a lot more traumatic social situations and non-DSM-V traumas. Non-DSM-V traumas are any events an individual feel was traumatic but are not currently considered traumatic under diagnostic criteria. Bullying, mental health problems, and cumulative minority stress may be considered non-DSM-V traumas.

Since assessment for PTSD is not built around autistic communication, there can also be an underdiagnosis of PTSD in autistic individuals.

Autism is characterized by an “abnormal” perception of sensory information. It also has many co-occurring conditions that affect perception, like alexithymia, hyperphantasia, and synesthesia.

A recent study indicated that Grapheme-Color Synesthesia, where individuals associate numbers or letters with colors or images, is associated with PTSD. Sensory systems play into the way PTSD symptoms affect an individual.

I couldn’t find any literature indicating whether autism affects the severity of PTSD symptoms, but there was evidence indicating PTSD affected autism symptom severity. Things like social skills and other emotional regulation skills were affected by PTSD, creating the appearance of more pronounced autistic symptoms as a result.

There needs to be more research into how the somatic experience of autism interacts with the experience of PTSD. Until we have more research, it is unclear how being autistic may affect flashbacks.

An exercise for flashbacks

While many coping skills can be helpful in dealing with flashbacks, I’ll leave you with my favorite.

The technique is called “what’s different?”. In the flashback, you ask yourself, “what’s different?”. You keep naming different things about the room until your body returns to the present. It can be anything like “it’s colder”, “there’s this person with me”, “the walls are a different color”, “I’m laying down”, etc.

While it sounds simple, it can be beneficial during flashbacks to remind yourself where you are.

How Do I Know if I’m Experiencing Burnout?

I’m burned out. Between the constant grind of school and work, moving, and the current state of my country, I am completely drained.

I am not alone. In 2021, 79% of U.S. employees reported experiencing work-related stress. Nearly 3 in 5 reported being negatively affected by work, including lack of energy, motivation, and cognitive fatigue.

There are many reasons for stress to pile up in modern life. Having constant access to the news 24/7, being isolated in individualistic cultures, collective traumas like the pandemic, a culture of productivity, and our personal history all contribute to this mass feeling of exhaustion.

What is burnout?

Burnout is a syndrome, not a disorder. This means that any person can experience it at some point in life and generally can process it without intervention from a professional.

To count as burnout, it needs to have three dimensions A person needs to be exhausted, experience cynicism or depersonalization, and have a negative self-view of performance.

Burnout is talked about in the literature solely as related to work. It was first coined to explain the collection of symptoms common among therapists and other service workers that experience chronic stress. Presumably, stressors outside of work can also cause burnout.

Burnout vs. trauma vs. depression

Burnout has a lot of shared symptoms with trauma and depression. It can make it difficult to pinpoint what the cause of the problem is and get proper treatment. Many people use the term burnout when they’re actually experiencing other issues.

The chart above is not exhaustive, and specific symptoms are subjective in where they fall.

Shared characteristics are exhaustion, depersonalization, cynicism, irritability, anxiety, helplessness, headaches, withdrawal from social, and numbness or emotional outbursts.

Some key differences about burnout are that it is usually short-term, that you can pinpoint the source of the stress, and that self-care can prevent it. You can also start with burnout, which leads to depression if prolonged enough.

If your symptoms last a while, you’re experiencing suicidality, you’re getting intrusive thoughts and flashbacks from the source of stress, you have physiological changes, or you’re feeling down most of the time, you should seek professional help. This would indicate you are not experiencing burnout but are experiencing something else.

Common causes of burnout

Something that is not often discussed in the context of burnout is that it is mainly organizational. We typically put it on people as their responsibility to fix their burnout when the organization has a climate that leads people to burnout.

Sweden provides employees paid time off for burnout and other stress-related illnesses. Burnout researchers found that although they got this time off to rest, many employees still didn’t want to return to the workplace. You cannot fix a poor organizational structure or fit by taking time off.

In one study, employees rated their bosses and found that for every point increase in leadership score, there was a 7% decrease in burnout and an 11% increase in job satisfaction.

The most common work structure factors that lead to job satisfaction or burnout are:

  • Workload – how much you’re doing
  • Reward – work incentives/meaning
  • Control – how much autonomy you have
  • Community – the work culture and relationships
  • Fairness – if employees are treated equally
  • Values – your personal values vs. the company’s

If any of the above areas is poor in a given work environment, you will experience stress and less job satisfaction.

Autistic burnout vs. occupational burnout

While autistic and occupational burnout shares a name, the two are distinct. Autistic burnout is a relatively recent term, so the clinical literature is sparse, but the available research points to autistic burnout being longer lasting (up to years), decreased tolerance to sensory stimuli, barriers to treatment preventing relief, and issues with living independently.

Autistic people can also experience occupational burnout, contributing to autistic burnout. The symptoms look similar, but autistic burnout is more severe and enduring.

Like other forms of minority stress, contributions to autistic burnout are the cumulative load of expectations combined with systemic barriers to treatment Things like masking, transitions, dealing with the debilitating parts of autism, and social expectations fray the rope of stress management. Being dismissed by others, poverty, poor boundaries and self-advocacy, and not taking a break causes no relief from the stressors.

More research needs to be done on the condition and the best recovery methods. The early research on autistic people’s perspectives indicates that setting boundaries, asking for help, doing wellness activities, and recognizing autistic traits/diagnosis all alleviate autistic burnout.

Solving Burnout

You’ve tried all the self-care under the sun, and you’re still burned out. You’ve been told repeatedly that you need to take time off to solve your problems when that would only lead to more problems. You’re stuck in a cycle of waking up, dreading work, going home, dreading work, and going to bed.

I get it. Burnout is really hard. And unfortunately, there isn’t a magical solution.

You cannot self-care your way out of burnout. Self-care is meant to be preventative, not an intervention.

The first question you have to answer is: is it me or my job? If you look at the lists above and see that your company is missing several crucial dimensions, it may be time to start job hunting. Trying to solve burnout when the organizational problem is like that art installation where the robot is trying to clean up a constant pool of blood.

If it’s not an organizational problem, here are some tips that can help.

  • Disconnect from your phone. Set digital wellness timers, limit the content you’re seeing, and take a break from the news.
  • Prioritize responsibilities. Think of your responsibilities as juggling balls. Some are made of glass, and others are made of plastic. Figure out which ones are glass and focus on making sure those don’t drop. You’ll be fine if you drop the plastic responsibilities for a bit.
  • Take your breaks at work. Use PTO. Think of it as investing in your productivity.
  • Talk to someone, preferably a therapist. Verbally processing your situation can help you realize what will work.
  • Have a physical outlet. Our bodies naturally try to physically shake off stress, but we often inhibit it. Animals shake in the wild to relieve acute stress.
  • Do the wellness activities you can. You can’t do everything, but choose what’s most important.
  • Set time between responses. Most communication doesn’t require an immediate response.
  • Engage the parasympathetic nervous system. “Tricking” your body into calming down will boost your energy and mood.
  • Do nothing. Boredom can be beneficial in sparking creativity and letting your mind rest.

Remember, you are worth more than your job. Your inherent value is not tied to your productivity. You are worth just as much when you’re burnout as when you’re at your peak productivity.

FAQ 2: Why is Applied Behavior Analysis Controversial?

For definitions of terms, please check out FAQ 1.

Table of Contents

  1. What is “New ABA”? – A brief history of ABA
  2. Why is it controversial?
    1. Requirements for Practice
    2. Issues with Consent/Assent
    3. Reducing Humans to Animals
    4. Suspect Evidence Base
  3. How does ABA differ from parenting?
  4. Is there any “Good ABA”?

What is “New ABA”? – A brief history of ABA

CW: This section describes abusive practices in ABA. Reader discretion is advised.

Historically, ABA was known for harsh punishments (aversives) like beatings, spray bottles, verbal harassment, withholding food, public shaming, and shock treatment. The original goals of ABA can be summed up well by the most-attributed “founder of ABA,” Ole Ivar Lovaas.

“[Y]ou start pretty much from scratch when you work with an autistic child … they are not people in the psychological sense.”

Ole Ivar Lovaas, attributed ‘founder of ABA’

One of the major criticisms of “original ABA” is that its methods heavily influenced Lovaas’s involvement in The Feminine Boy Project, which was foundational to conversion therapy for gay and trans youth.

The rhetoric of ABA initially promoted itself as the only known “cure of autism.” Since the punishments were seen as preferable to institutionalization, the harm was rationalized and widely supported by the medical field and parents.

When considering the rise of Autism Speaks through cure rhetoric, it explains why the two are often connected. Autism Speaks has also pushed legislation to get ABA mandatory insurance coverage in many states, legitimizing the practice. ABA set the stage rhetorically for Autism Speaks, and the two mutually benefit from pushing parents towards seeing autism as in need of immediate intervention before it’s “too late.”

ABA also positioned itself as the only scientifically supported autism therapy, shunning other therapies as pseudo-scientific and ineffective. This is similar to how behaviorism arose from rhetoric regarding it as the sole objective psychological science. It was later recognized as lacking crucial dimensions (like unobservable, internal states) to treat holistic mental health.

Over time, original ABA methods like Discrete Trial Training (DTT) were missing crucial components like the generalizability of outcomes. New methods like Naturalistic Environment Teaching (NET) along with a wide array of variants like EDSM, PRT, PBS, and PECS were introduced. The aversive punishments received negative attention and were regarded as inhumane.

ABA outwardly shifted to focusing on naturalistic, child-led, rewards-focused interventions in an attempt to ethically practice ABA. The original goals remain the same; improve communication/adaptive skills, and reduce “problem behaviors.”

This coincided with the first wave of people that went through ABA becoming adults; many spoke out about the traumatic experiences where they were forced to stop being autistic at threat of violence.

While there is no set period in time where this change emerged, from my understanding, there was a progressive shift in ABA to distance itself from its historical past.

If you talk to most ABA therapists, they would agree that the “old ABA” was bad. They claim that the “new ABA” is good, pointing to advancements in naturalistic techniques that are not as explicitly punitive. This “old ABA” vs. “new ABA” has served to silence people that experienced ABA, regarding them as having old ABA and therefore not having an informed perspective on current ABA practices.

Autistic ABA survivors and others in the community point to how many of the techniques that caused harm are still present and that because the goals are still the same, they still punish autistic expression and favor making autistic children more like their neurotypical peers.

It is also worth noting that there are still ABA organizations highlighted at major ABA conventions practicing electric shock torture at the Judge Rotenburg Center (JRC). They recently went after an autistic-run non-profit for publishing statements regarding the inhumane treatment. The “old ABA” is not so distant as ABA therapists tend to argue.

Why is it controversial?

Requirements for Practice

Currently, only 31 states in the U.S. require a BCBA to be licensed with the state (with a few states with proposed legislation). This means that, unlike other therapy professionals, many states have no external body of regulation for ABA professionals. They are still required to get certified through the BACB to practice, but the BACB is an independent body that can decide the rules for certification and what qualifies.

Considering other blatant unethical processes in the field, like the JRC, the BACB has some apparent conflicts of interest in judging ethical conduct. This is why an external regulation body is necessary to maintain ethical conduct.

Another concerning aspect is that currently, no states require a license for RBTs. They are essentially practicing therapy without a license, with minimal training, and all under the guise of being supervised by someone with more credentials. I can’t think of the equivalent of an RBT in any other type of therapy because it’s broadly recognized that the level of experience and training necessary to practice is far beyond what an RBT has.

There are also no strict guidelines for learning about autism or child development for any ABA therapist.

Below, I’ve created a table using Washington State, one of the 31 states with licensing requirements for BCBAs, RBTs, and Licensed Mental Health Counselors (LMHC). While there are different pathways for BCBAs and LMHCs, I used the most common technique for obtaining licensure for each.

Supervised Practice HoursDirect SupervisionContinuing Education (Every 2 years)
BCBA (WA State, USA)1500 hrs75-150 hrs32 hrs
RBT (WA State, USA)40 hr classroom training (not practice hours)5% of hours post credential, 2.5% individual0 hrs
Mental Health Therapist (WA State, USA)2500 hrs100 hrs36 hrs
Licensure Eligibility Requirements for BCBAs, RBTs, and LMHC

Another concern is that many ABA interventions inherently don’t offer the option to consent or even punish when a client does withdraw consent.

Some ubiquitous issues with consent in ABA are pairing, improper understanding of accessibility needs (including minimal verbal options for non-speakers), punishing “vocal non-compliance,” and using fidgets, breaks, food, or other needs as reinforcers. Many also don’t present a choice to engage with the intervention, use restraint and seclusion, remove loved reinforcers from home to “make them more effective,” and don’t understand meltdowns or how to prevent them.

In theory, the behaviors targeted for reduction and increase should be purely for the client’s benefit. However, many clinics use the parent’s perspective to form goals. Many providers (often unconsciously) set goals to help make the parents’ lives easier, like teaching them to say hello to their parents or stop screaming to help parents focus. Taking parents’ thoughts into consideration isn’t inherently a bad thing. When ABA often uses rigid behaviorism tactics, you force compliance regardless of their interest if it is not for the client’s benefit. It would only take one goal not made for the client’s benefit in the 40 hours per week of ABA for it to become unethical. Not many other therapies give the therapist so much control over their client.

Nothing in the ethical code directly specifies in which contexts the client is the kid vs. the parent. This also leaves murky areas for prioritizing the parent as an ethical choice.

The prompt hierarchy is another example of issues with consent. One of the issues with the prompt hierarchy is that it assumes all behavior is willful or incompetent. It believes that if someone isn’t doing something you’ve asked, they either do it because they don’t want to or don’t know how to. Working with a population with many co-occurring disabilities necessitates determining if the behavior isn’t happening due to motor, physical, or other unseen interworkings. It also requires physical force to complete a task if a child isn’t responding.

For example, when I worked in ABA, a child struggled to put on their shoes. I was supposed to work through the prompt hierarchy, but I paused and considered the environment. I realized that the kid was embarrassed, as he had two adults pressuring him to put on his shoes, a behavior he already knew how to do but was struggling with that day. I waited for him and let him know there wasn’t a rush to the next activity, and immediately he was able to put on his shoes and looked incredibly relieved.

Reducing Humans to Animals

Another concern about ABA is that it completely ignores internal states. It believes that humans can be reduced to behaviors that can be explained and manipulated. There is no room to analyze emotions or other physiological states that can’t be observed. This is also why there is sparse research examining ABA’s psychological and emotional effects in the short and long term.

Take the four functions of behavior, for example. While the four functions of behavior may appear logical, it is reductivist and only sees human behavior as four categories. Since it is phenomenological, you can point to anything as “evidence” for those categories.

I could categorize human emotions into good, bad, and weird. I could categorize my feelings as happy, content, and excitement are good; sad, lonely, and angry are bad; and confused, off-put, and deja vu are weird. Obviously, there are only three human emotions now! The evidence is that every feeling I experience can fit into these three categories.

It’s rational to see how this line of thinking is faulty.

Suspect Evidence Base

Methodologically, behaviorism created single-subject designs to measure baseline and subsequent behaviors, and this has been the foundation of much of ABA’s evidence base.

While single-study designs can help prove a behavior has successfully changed, they are not generalizable to broad populations. They also only prove that the behavior successfully changed. They don’t adequately address any effects of the intervention beyond behavior change.

Beyond this, a proper control group is not typically used in multiple subject designs in ABA research. There are only groups where children receive interventions and no groups that show whether the behavior would have developed without the intervention.

There are many Conflicts of Interest (COIs) not disclosed in ABA research. One study examining ABA literature found that 87% of the 70 studies with no declared Conflict of Interest found at least one author who provided ABA services or consultancy for ABA providers (clinical/training COI). They also found that only 5 studies out of 180 were group designs instead of single-case designs.

It is worth noting that there is a lack of transparency about the widespread methodological issues. That is significant considering that this evidence base has been used to receive government funding, support from the medical field and the public, recognition from the largest autism non-profits, and hundreds of thousands of dollars from insurance and parents. It has also contributed to other therapies for autistic children not being covered by insurance companies and disregarded by the court system, forcing many families into needing care with ABA as the only option.

How does ABA differ from parenting?

While the two may look similar, ABA differs in application, goals, and systemic power.

I do not have children. I will be very clear that my perspective of parenting may be incomplete.

Most parents’ goal is to raise a happy and pro-social child, where they are secure in themselves and actively try to better the community. Obviously, this isn’t the case for all parents, but when comparing the two, it’s easier to establish a baseline.

ABA is not simply reinforcement. We use reinforcement regularly in our daily lives, which is very important in parenting.

To examine the differences, it’s helpful to look to ABA “parent training,” where therapists will often come to the parent’s home and teach the parent how to practice ABA when the child is not with the therapist. The therapist will often instruct parents to make reinforcers sparse so that the child has to communicate for them. The therapist will instruct parents on how to apply reinforcement and punishment, how to gain the child’s attention, the prompt hierarchy, identifying the functions of the behavior, and the motivating operations (circumstances that make reinforcers work better).

In parenting, typically, this level of structure is absent. Suppose we’re discussing “gentle parenting” (authoritative parenting). In that case, it advocates for natural consequences and rewards — which with NET may be similar but is not similar to other types of ABA. Authoritative parenting would place boundaries around access to reinforcement but would recognize giving access to loved items without demands is necessary for warmth and would never withhold food for the sake of compliance.

Gentle parenting would believe in errorless teaching but likely wouldn’t resort to physically restrictive methods like hand-over-hand. Authoritative parenting doesn’t reduce a child’s actions into behaviors with functions but instead notices the emotional motivations and is empathetic to the child’s internal states.

So, ABA is more akin to authoritarian parenting, which requires compliance and lacks warmth. ABA differs from any parenting style in that it has systemic power. It can be used to take kids away from parents if they don’t comply with treatment, regardless of how much it costs. It uses rhetoric discussed earlier to lure parents into believing their child is broken. It has legislative power allowing it to exist instead of therapy without a therapy licensing board.

Parenting is not ABA. Even authoritarian parenting.

Is there any “Good ABA”?

If you converse with an ABA provider about ABA, you will quickly hear the argument, “I practice good ABA.” Every provider believes they do. To be fair, there are many risks to examining your own practice and whether you are practicing “ethical ABA.” Most ABA providers go into the field because they genuinely care about other people and see ABA as a way to help. But, many ABA therapists still practice the problematic interventions I’ve identified here.

This is the heart of the ABA controversy. Is there any such thing as good ABA? I’ve interviewed autistic ABA practitioners and ABA survivors. Many people don’t believe that there is an ethical form of ABA. At its core, ABA does believe in changing behaviors with disregard for internal states, which is manipulation. And while manipulation can be used for the benefit of someone, how can we say that it’s in the client’s benefit when so many are coming forward with hidden harms of ABA (both new and old)?

That’s not to say that individual people have not benefitted from ABA. Some people have. There’s a lot of nuance to the conversation when considering the client’s racial, cultural, socioeconomic, location, clinic, and accessibility needs. As a consequence, it’s hard to say for sure what the appropriate action is.

Many call for an overhaul of ABA and go about it differently. Some believe they can change it within the field. Others believe the field is too corrupt to fix. Some risk their licenses or livelihoods in the pursuit of ethical treatment. And many more are complicit in a demonstrably unhealthy environment.

There are some critical changes that the field needs to make before it can be considered safe. And it needs to be a field where the unethical practices are not so pervasive that trying to pick an ABA provider is a minefield because you can’t tell on the surface which is the “good one” vs. the “bad one.”

Another question is, if the field does change so significantly that it becomes ethical, would it even be able to be called ABA? When some foundational techniques (behavior manipulation on vulnerable populations) have such a high potential for harm, can we ever be confident that we can ethically practice this goal?

Some practice ABA in name alone. Unfortunately, there’s not much one can do with a degree in ABA outside of ABA, and many insurances do not cover any autism therapy outside of ABA. So, some providers will provide other services and still call themselves ABA providers since that is what they’re certified in. This further complicates which ABA providers are “good ABA.”

This is not a new debate. This debate has been around as long as behaviorism, with psychodynamic therapy taking its place. Behaviorism on its own is generally not practiced outside of ABA. Therapists have considered it unethical when practiced alone without a multi-modal approach.

Regardless of the solution, it seems like ABA will have to become multi-modal, have better regulations, methodology, procedures for consent, education, humanistic goals, and consideration for the autistic community to start being an ethical field.

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