Is “Pairing” in ABA The Same As Therapeutic Rapport?

CW: The following article discusses the implementation of ABA interventions. Reader discretion advised.

I was sitting with my non-speaking client, him holding up some blue edible playdough his mom made. I smiled back, and we both snuck a bit to eat, enjoying the salty-sweet-doughy taste.

I had spent weeks just playing with him, developing a relationship. He felt safe and loved because I played with him and gave him my full attention.

A couple weeks after that, I began implementing his programming. Our fun playdough time of making weird shapes and eating the playdough turned into a rigid activity to teach him letters.

I asked him, “touch A!” as I laid out letter stencils. If he chose the correct one, I would press it on the playdough, and we would get to play with it. He enjoyed our game and responded correctly the first few times.

I was inexperienced and didn’t understand autism well enough at the time to understand the following events. He seemed happy, grinning at me and playing with his playdough. I felt pressured to get in as many trials as possible, counting them on my iPad because they proved to my superior that I was a good therapist.

I pushed him repeatedly, rewarding him only when he gave the correct answer, or I grabbed his hand and had him touch the right answer. I followed the prompt hierarchy like I was supposed to.

Suddenly I asked him, “touch O!” and he threw himself onto the ground, banging his head and crying. I was distressed, trying desperately to calm him down. I put safety mats under his head and panicked, telling him it would be okay. Eventually, I learned that if I stopped talking, he was able to self-regulate.

I didn’t understand how our positive relationship had instantly turned into a distressing one. It seemed like the behavior “came out of nowhere.” I didn’t understand the stress he felt when I switched from showing him unconditional positive regard to suddenly making it conditional. He wanted to do what I asked because he cared about me, but I wanted more and more and more.

I was doing a process called “pairing” in ABA. Pairing is the process when a practitioner develops a relationship with a client to become a source of reinforcement themselves. When the therapist is a reinforcer, success in changing behavior in ABA skyrockets.

Often the first few weeks with clients are spent exclusively pairing. From an ABA therapist’s standpoint, the benefits seem like a no-brainer. The kid should want to spend time with you and enjoy your time together. You should learn what they like and don’t.

For survivors of ABA, the motives are more sinister. Pairing has been called manipulative because many therapists then weaponize that relationship to gain compliance.

Both have strong arguments with significant consequences. Therapeutic rapport is well documented as one of the most necessary steps in therapy, but it creates harmful results if it is manipulative.

So, is pairing manipulative or good therapy?

Therapeutic Rapport

Therapeutic rapport has been long established as a necessary part of successful therapy and medicine.

Research on therapeutic rapport suggests that to develop rapport, a therapist or other healthcare provider should use active listening, maintain an open posture, be honest, and alter their behavior so their client can interpret it (pg. 151).

Clinicians must focus on cultural competency with therapeutic rapport and considering their client’s unique circumstances. When there is a discrepancy in power, whether cultural, economic, or social status, there’s an increased need for caution. A therapeutic relationship could quickly become manipulative or harmful if these factors are ignored.

Altering behaviors so clients can interpret them is especially relevant to autism. A therapist’s body language must be able to be interpreted by their autistic client, and consideration taken for whether their body language can be easily decoded. Without this, the therapist could easily convey meanings that are not intended and/or further distress the client.

Eye contact is also something that should not be present in therapeutic rapport for autistic individuals, though this is often recommended. With non-speaking clients, active listening of vocal language may not be possible; though active attention to non-vocal signals is necessary.

So, therapeutic rapport for autistic people is necessary for robust therapy. Is pairing a good way to go about it?

Why do Some People View Pairing As Manipulative?

Love bombing is the process in which the person in the relationship is showered with gifts and positive regard with the goal of emotional dependence. After the person develops feelings for the person they’re with, the gifts and attention are removed and become conditional, creating an inconsistent, stressful environment. This can further lead to abusive situations if the person doing the love bombing isn’t receiving compliance.

“Lieu, this sounds pretty extreme. Weren’t you just talking about therapeutic rapport and its benefits to clients?”

You’re right, it is an extreme comparison. But it is necessary to understand the difference between healthy therapeutic rapport and manipulative rapport that fosters dependence on the therapist.

Pairing gives children unconditional access to reinforcers like their favorite items, activities, and even food preferences. The therapist provides the child with their full attention and doesn’t make any demands, showing interest in whatever they are doing.

After the child is bonded to the therapist, the reinforcers are conditional. The attention is contingent. And the child has to comply with demands to receive this loving support to which they’ve grown attached.

Add to this the power dynamic between an adult in complete control of the child’s access to their preferred items, with the powerlessness of the child to control what is targeted in therapy. The relationship is set up to create ethical issues.

That isn’t to say every relationship with children after pairing will become manipulative. But all it takes is one therapist who doesn’t apply a goal correctly, acting under the wishes of a parent over the child’s interests, or is facing pressure to meet a quota of goals. It becomes clear how this relationship could easily be weaponized.

Practices like “planned ignoring” and “extinction plans” require therapists to withhold their positive regard or access to reinforcement until the child completes the behavior they need to see.

This creates a distressing environment because children are desperate to get back into the therapist’s favor. They want that positive attention and want to feel loved by their therapist. Making that contingent teaches children several problematic lessons like compliance as love, non-compliance as unworthiness, and positive regard being conditional.

“Pairing is Just Therapeutic Rapport!”

Now that we’ve examined therapeutic rapport and pairing, it is necessary to understand why pairing should not be considered therapeutic rapport.

One of the key things that separate it from therapeutic rapport is the intentional removal of reinforcement.

Imagine starting therapy with a cognitive therapist who showed unconditional positive regard, openness, and altered their behavior to help you interpret it. You feel comfortable expressing your vulnerabilities and may even cry, breakdown, or tell them things you’ve never told anyone.

After five sessions of doing this, the therapist suddenly becomes cold and closed to you. They tell you for therapy to work, you have to stop crying when you come into therapy. It’s labeled as a “maladaptive behavior” and targeted for reduction. When you go the whole session without crying, she smiles at you and shows you the same level of attention you received in the beginning. You may feel confused or distressed by this sudden switch in demeanor.

Would you go back to this therapist? What if you didn’t have a choice?

There’s no point in therapeutic rapport in any other therapy type where the aspects of therapeutic rapport are reversed.

Further, suppose this is at a clinic where the therapists receive little to no education on aspects of autism. They may be incapable of modifying their behavior to be interpretable to clients. They may assume that their behavior is perfectly fine and it’s the client that is refusing to make an effort to interpret.

“My Client Loves Being Around Me, I Would Never Harm Them”

It’s a thought I had when I was in ABA. How could I be harming anyone if I was met by smiles, excitement, and unprompted bids for attention?

I certainly had no intention of harming anyone. I was there because I wanted to help, and in my mind, I was! I was taught that a behavior change was a marker of success, so I was clearly succeeding through a tangible measure of progress.

I ignored how “maladaptive behaviors” that clients experienced during my sessions may be an indication that everything wasn’t rosy. I ignored the meltdowns, the non-responsiveness, the times when I pushed too hard or didn’t understand the cause of their behavior. I ignored my contribution to the behaviors that “seemed out of nowhere.” And I saw it happening with other therapists, but no one seemed to see anything wrong.

It’s a scary thought, but you can harm someone without intending to. And if you’ve dedicated years to something to try to help someone, you have a lot of incentive to ignore those adverse outcomes.

If you’ve read this far and are an ABA therapist, I genuinely applaud you. It’s hard to examine your own flaws, and it’s clear you’re trying to do better. Otherwise, you wouldn’t be here.

If you’re looking to do better, look into how to develop therapeutic rapport. Do research on autistic traits and how to make your behavior easier to interpret for an autistic person. And replace pairing with developing evidence-based therapeutic rapport.

Clients deserve transparency in their therapy, including their expectations beyond initial impressions. Don’t set a false expectation of the treatment you’re practicing through pairing.

One Year Traumaversary of My Job at “The Good ABA”

Here is my experience with ABA: https://lifeoflieu.com/2022/01/22/i-was-part-of-the-good-aba/

Working in ABA was genuinely traumatic for me. Every night, I woke up in a sweat, nightmares plaguing me with how I was treated and my powerlessness. When I worked my next job, I had a hard time expressing myself because I was so scared of being hated for being autistic. I didn’t just burn out, I imploded.

To gain sanity with a situation where I was gaslit daily, I started speaking out. I never intended to become an advocate, but I naturally found myself in advocacy when I needed validation that what I was experiencing was as bad as I felt.

It’s incredible that it’s been a year since I left my job in ABA. So much has been accomplished in such little time. I’ve been able to tell my story to over a million people, have received letters from countless practitioners thanking me for helping them understand the problems in their field, and was able to get an autism diagnosis.

But the first-year traumaversary is always the worst. You start getting triggered over the most random things, nightmares rear their ugly head, and emotional flashbacks come in waves. So, to put that energy somewhere productive, I’ve come up with some takeaways from my experience.

While reflecting on this year, here’s a list of 5 things I learned about myself and ABA.

1. Don’t sign a contract that requires you to pay money if you quit.

When you want to work a job badly enough in a field you’re passionate about, it’s easy to overlook the warning signs. Seems obvious, and yet I still did it, so you could too. It indicates high turnover and locks you into the company. It’s the “don’t marry a man you just met” of the professional world.

Because ABA often hires young 18-22 yrs old fresh out of high school, many are inexperienced with the professional world. This leaves them vulnerable to exploitation from their companies and toxic power dynamics with their superiors.

I’d imagine my experience with this is also not uncommon. Companies that do this restrict their practitioners from leaving which leads to bad outcomes for everyone involved.

2. ABA is omnipresent and restricts access to services.

ABA is EVERYWHERE. It has dominated autism therapy. Even other therapies like occupational therapy and speech-language therapy are now using ABA. If you don’t want ABA, you’re out of luck in most places.

ABA shuts down valid critiques by dismissing them as “not understanding ABA” or having some vendetta against the science. It has portrayed itself as the “only cure to autism” to the point that other therapies are no longer available and shuts down the voices of the population it serves. I’m not the only one that believes this. Researchers have remarked that it’s “ideological warfare.”

Callahan et al. (2009) ran a study where they de-identified ABA and TEACCH (a therapy focused on working on the underlying elements of the behavior of autistic people) and showed that when they removed the labels ABA and TEACCH, people rated the treatment by their descriptions as equally effective. This finding was contrary to the “ABA is the only way” advocacy done by ABA professionals and parents. ABA advocates present non-behavioral interventions as not evidence-based, which is just false.

This attitude is pervasive among ABA professionals and parents. I remember ABA presented as a miracle cure for autism. This evidence supported changing problematic behaviors like self-harm and aggression while increasing communication.

It came as a shock to me later that there weren’t investigations into outcomes other than behavioral as far as what was considered successful. ABA was replacing other evidence-based practices and claiming it was the only one. It made all of these claims and yet didn’t educate its practitioners on fundamentals like communication, autism characteristics, and other therapies.

3. Unethical practice isn’t usually committed by “Unethical People.”

“It requires conducive social conditions, rather than monstrous people, to produce heinous deeds.” – Albert Bandura.

To sum up my experience, people that cared deeply about autistic children committed the unethical practices I witnessed. This care doesn’t excuse their actions, but it was astonishing to watch the step between having excellent intentions and doing horrible things. The two are much closer than is comfortable.

So, how does abuse happen? When you believe what you are doing has such profound consequences that you are saving another person, it’s easy to justify any “momentary discomfort.”

Discomfort is inevitable in life. What becomes necessary discomfort vs. unnecessary? It’s easy to see how someone might believe what they are doing is necessary discomfort when comparing it to the usual things we encounter in life. Particularly if that person is neurotypical, they may not fully grasp the physical pain experienced by sensory stimuli that they find as just annoying.

My supervisor wasn’t a monster. She was an overworked, underpaid practitioner who genuinely wanted to help the children she worked for and tried to study contemporary literature/practice. She was in a clinic run by a woman who viewed herself as saving her son with “severe autism” through ABA, which enabled the social conditions for anything to be justified in pursuit of a cure.

And that’s why my supervisor objected to me “calling her actions abuse.” In her mind, it wasn’t abuse. It was “allowing mom a moment of free time,” “keeping the child safe from extreme behaviors like self-harm,” and “teaching him to tolerate the sensory harshness of the real world.”

I want to emphasize that what she did was absolutely abuse. She tortured a kid for 20 mins to make them cry and laughed about his PTSD symptoms exhibited after. But, it’s understandable how she committed that unethical act despite her attempting to be an “ethical person.”

4. The BACB is one of the most ineffective ethical bodies.

The BACB has incredibly loose guidelines around ABA’s ethics, allowing almost anything to count as ethical. Most of the ethics focus on treatment fidelity, not on client dignity. And for them to investigate a case, you must come with documentation. They will not investigate themselves, only look over the evidence you present. It’s why I ended up not reporting.

They are also not overseen by any department. State to state, there are differences in how licenses are involved, but there is no overarching licensing body that is not tied to ABA. Unlike therapists, they are not required to report to a “state ABA licensing board”. And even in states that allow BCBAs to be grandfathered in as licensed practitioners, RBTs are often not.

And that’s not to mention they allow shock devices to be used with autistic people due to this loose ethical code like in the case of Judge Rotenberg Center. Shock devices. In 2022. This isn’t the “ancient” history of doing barbaric things to psych patients. This is modern history and not only legal, but ABA’s main ethical body also approves of it. If that’s considered an acceptable aversive, pretty much anything goes.

Carol Millman puts it well: “Only three subsections in the Behavior Analyst Certification Board’s professional code of ethics even address the wellbeing of the learner…The BACB says nothing about inflicting pain. There’s nothing in the BACB ethics code [that] says you can’t use electric shock. In fact, it doesn’t say anything at all about what type of ‘aversives’ are acceptable.”

I remember first learning about shock devices as a practitioner, and my gut reaction was, “well, our clinic doesn’t do that!”.

To practitioners reading this, listen closely. The problem is more extensive than shock devices (though that should be a red flag). The problem is that the governing ethics body allows the use of shock devices, which means that there’s a lot of unethical conduct that they also allow.

Just because you haven’t had the BACB contacted, or you have, and they deemed your actions ethical, does not mean that you are acting ethically. And that’s a poor standard for an ethics body.

5. Trust your gut.

Okay, this one seems obvious, but it’s easy to lose yourself at a job. Capitalism is a cruel master that conditions you to trust your boss and enforces a strict hierarchy. As an RBT, you are motivated to shut up and listen to your BCBA. This creates a culture of compliance. I’ve seen it now in other clinics and the one I worked at where BCBAs will try to use ABA on the RBTs they supervise. This is wildly inappropriate and not within their scope of practice. Not to mention is a massive break in consent.

Something deep inside you lets you know whether what you’re doing is moral. We’re all biased towards believing we are moral (and often ignore signs that we’re not), but if you’re questioning whether a decision you made is ethical, it’s a sign to take a step back and assess the situation. Get opinions outside your field, especially from the clientele you serve. Reach out to ethics hotlines and ask the internet. Find information from unbiased sources. And listen to your gut. If something feels off, it probably is.

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I’m so grateful to be out. I’ve learned a lot from my experience, and I hope this can shed light on others’ situations so they don’t have to learn the lesson I did the hard way.

It’s funny how the most traumatizing experiences can fundamentally shape your life. I can thank my old clinic for that. It showed me I was autistic by ruthlessly punishing autistic expression and gave me a direction for the therapy career I’m pursuing. So thanks, I guess.