CW: The following article discusses the implementation of ABA interventions. Reader discretion advised.
I was sitting with my non-speaking client, him holding up some blue edible playdough his mom made. I smiled back, and we both snuck a bit to eat, enjoying the salty-sweet-doughy taste.
I had spent weeks just playing with him, developing a relationship. He felt safe and loved because I played with him and gave him my full attention.
A couple weeks after that, I began implementing his programming. Our fun playdough time of making weird shapes and eating the playdough turned into a rigid activity to teach him letters.
I asked him, “touch A!” as I laid out letter stencils. If he chose the correct one, I would press it on the playdough, and we would get to play with it. He enjoyed our game and responded correctly the first few times.
I was inexperienced and didn’t understand autism well enough at the time to understand the following events. He seemed happy, grinning at me and playing with his playdough. I felt pressured to get in as many trials as possible, counting them on my iPad because they proved to my superior that I was a good therapist.
I pushed him repeatedly, rewarding him only when he gave the correct answer, or I grabbed his hand and had him touch the right answer. I followed the prompt hierarchy like I was supposed to.
Suddenly I asked him, “touch O!” and he threw himself onto the ground, banging his head and crying. I was distressed, trying desperately to calm him down. I put safety mats under his head and panicked, telling him it would be okay. Eventually, I learned that if I stopped talking, he was able to self-regulate.
I didn’t understand how our positive relationship had instantly turned into a distressing one. It seemed like the behavior “came out of nowhere.” I didn’t understand the stress he felt when I switched from showing him unconditional positive regard to suddenly making it conditional. He wanted to do what I asked because he cared about me, but I wanted more and more and more.
I was doing a process called “pairing” in ABA. Pairing is the process when a practitioner develops a relationship with a client to become a source of reinforcement themselves. When the therapist is a reinforcer, success in changing behavior in ABA skyrockets.
Often the first few weeks with clients are spent exclusively pairing. From an ABA therapist’s standpoint, the benefits seem like a no-brainer. The kid should want to spend time with you and enjoy your time together. You should learn what they like and don’t.
For survivors of ABA, the motives are more sinister. Pairing has been called manipulative because many therapists then weaponize that relationship to gain compliance.
Both have strong arguments with significant consequences. Therapeutic rapport is well documented as one of the most necessary steps in therapy, but it creates harmful results if it is manipulative.
So, is pairing manipulative or good therapy?
Therapeutic Rapport
Therapeutic rapport has been long established as a necessary part of successful therapy and medicine.
Research on therapeutic rapport suggests that to develop rapport, a therapist or other healthcare provider should use active listening, maintain an open posture, be honest, and alter their behavior so their client can interpret it (pg. 151).
Clinicians must focus on cultural competency with therapeutic rapport and considering their client’s unique circumstances. When there is a discrepancy in power, whether cultural, economic, or social status, there’s an increased need for caution. A therapeutic relationship could quickly become manipulative or harmful if these factors are ignored.
Altering behaviors so clients can interpret them is especially relevant to autism. A therapist’s body language must be able to be interpreted by their autistic client, and consideration taken for whether their body language can be easily decoded. Without this, the therapist could easily convey meanings that are not intended and/or further distress the client.
Eye contact is also something that should not be present in therapeutic rapport for autistic individuals, though this is often recommended. With non-speaking clients, active listening of vocal language may not be possible; though active attention to non-vocal signals is necessary.
So, therapeutic rapport for autistic people is necessary for robust therapy. Is pairing a good way to go about it?
Why do Some People View Pairing As Manipulative?
Love bombing is the process in which the person in the relationship is showered with gifts and positive regard with the goal of emotional dependence. After the person develops feelings for the person they’re with, the gifts and attention are removed and become conditional, creating an inconsistent, stressful environment. This can further lead to abusive situations if the person doing the love bombing isn’t receiving compliance.
“Lieu, this sounds pretty extreme. Weren’t you just talking about therapeutic rapport and its benefits to clients?”
You’re right, it is an extreme comparison. But it is necessary to understand the difference between healthy therapeutic rapport and manipulative rapport that fosters dependence on the therapist.
Pairing gives children unconditional access to reinforcers like their favorite items, activities, and even food preferences. The therapist provides the child with their full attention and doesn’t make any demands, showing interest in whatever they are doing.
After the child is bonded to the therapist, the reinforcers are conditional. The attention is contingent. And the child has to comply with demands to receive this loving support to which they’ve grown attached.
Add to this the power dynamic between an adult in complete control of the child’s access to their preferred items, with the powerlessness of the child to control what is targeted in therapy. The relationship is set up to create ethical issues.
That isn’t to say every relationship with children after pairing will become manipulative. But all it takes is one therapist who doesn’t apply a goal correctly, acting under the wishes of a parent over the child’s interests, or is facing pressure to meet a quota of goals. It becomes clear how this relationship could easily be weaponized.
Practices like “planned ignoring” and “extinction plans” require therapists to withhold their positive regard or access to reinforcement until the child completes the behavior they need to see.
This creates a distressing environment because children are desperate to get back into the therapist’s favor. They want that positive attention and want to feel loved by their therapist. Making that contingent teaches children several problematic lessons like compliance as love, non-compliance as unworthiness, and positive regard being conditional.
“Pairing is Just Therapeutic Rapport!”
Now that we’ve examined therapeutic rapport and pairing, it is necessary to understand why pairing should not be considered therapeutic rapport.
One of the key things that separate it from therapeutic rapport is the intentional removal of reinforcement.
Imagine starting therapy with a cognitive therapist who showed unconditional positive regard, openness, and altered their behavior to help you interpret it. You feel comfortable expressing your vulnerabilities and may even cry, breakdown, or tell them things you’ve never told anyone.
After five sessions of doing this, the therapist suddenly becomes cold and closed to you. They tell you for therapy to work, you have to stop crying when you come into therapy. It’s labeled as a “maladaptive behavior” and targeted for reduction. When you go the whole session without crying, she smiles at you and shows you the same level of attention you received in the beginning. You may feel confused or distressed by this sudden switch in demeanor.
Would you go back to this therapist? What if you didn’t have a choice?
There’s no point in therapeutic rapport in any other therapy type where the aspects of therapeutic rapport are reversed.
Further, suppose this is at a clinic where the therapists receive little to no education on aspects of autism. They may be incapable of modifying their behavior to be interpretable to clients. They may assume that their behavior is perfectly fine and it’s the client that is refusing to make an effort to interpret.
“My Client Loves Being Around Me, I Would Never Harm Them”
It’s a thought I had when I was in ABA. How could I be harming anyone if I was met by smiles, excitement, and unprompted bids for attention?
I certainly had no intention of harming anyone. I was there because I wanted to help, and in my mind, I was! I was taught that a behavior change was a marker of success, so I was clearly succeeding through a tangible measure of progress.
I ignored how “maladaptive behaviors” that clients experienced during my sessions may be an indication that everything wasn’t rosy. I ignored the meltdowns, the non-responsiveness, the times when I pushed too hard or didn’t understand the cause of their behavior. I ignored my contribution to the behaviors that “seemed out of nowhere.” And I saw it happening with other therapists, but no one seemed to see anything wrong.
It’s a scary thought, but you can harm someone without intending to. And if you’ve dedicated years to something to try to help someone, you have a lot of incentive to ignore those adverse outcomes.
If you’ve read this far and are an ABA therapist, I genuinely applaud you. It’s hard to examine your own flaws, and it’s clear you’re trying to do better. Otherwise, you wouldn’t be here.
If you’re looking to do better, look into how to develop therapeutic rapport. Do research on autistic traits and how to make your behavior easier to interpret for an autistic person. And replace pairing with developing evidence-based therapeutic rapport.
Clients deserve transparency in their therapy, including their expectations beyond initial impressions. Don’t set a false expectation of the treatment you’re practicing through pairing.
Life of Lieu 