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April 24, 2005
Recently Bob Frank, a member of our Board of
Directors wrote me as follows:
"I had dinner last weekend with some friends. One of the wives attending
works with the ______, ___ school system.
I spoke of my association with you and the fine work that the J.R.
Educational Center was doing. She was quite vocal in her denunciation of
using adverse therapy no matter what the circumstances. She claims that
there are no published scientific reports to establish the claim of long
term effectiveness.
Please review the enclosed materials she sent to me and give me ammunition
for my rebuttal.
Best regards"
____________________________________________
The following is a slightly modified version
of the letter that I sent to him in reply:
"Dear Bob:
I have reviewed the materials you sent to me regarding the use of aversive
treatment procedures. I have responded to the material that was highlighted
in each of the four documents you included.
Please forgive me for giving you a long answer, but the issue of the
"temporary" effect of aversive therapy is actually not a simple one to
explain.
First, what is meant by aversives and aversive therapy? All
behavior is affected by the consequences it produces. If the consequence
produced by a behavior, or that is arranged to follow the occurrence of the
behavior, causes it to occur more frequently in the future, we call
it an accelerating consequence. The lay term for this is reward.
If the consequence a behavior produces, or that is arranged to follow the
behavior, causes the behavior to occur less frequently in the future,
we call it a decelerating consequence. The lay term for this is
punishment.
Everyone uses rewards and punishments to influence the behaviors of others.
For example, schools and/or parents use the following practices as reward
procedures: approval;.smiles; point rewards; money rewards; prizes; granting
of privileges; and good grades. And they use the following practice as
punishment procedures: disapproval; frowns; point fines; money fines; bad
grades; removal of privileges; placing and keeping the individual alone in a
room or other area("time out"); and suspension from school or termination of
enrollment.
Certain punishments, when used for certain purposes, are considered by some
to be too severe to be allowed or approved. Two examples are the use a hand
spank on the buttocks to punish the misbehavior of a child, or the use of a
shock to the surface of the skin to punish self-abusive behavior of an
autistic child . Both are considered by some to be too severe to be employed
and it is these types of punishments that tend to be called aversives.
Treatment that employs such procedures is called aversive therapy
or aversive conditioning. So aversives are essentially a subset of
punishments -- those that are considered by some too severe to be employed
and which, therefore are considered by them to be "politically incorrect."
So the question as to whether aversives have long-term effectiveness is
essentially the same question as to whether punishments have long-term
effectiveness.
Regarding the issue of the long-term effectiveness of punishment, much
depends on what type of punishment one is using and on what is happening in
the "long term." In the case of certain types of physical punishments, such
as a spank to the buttocks, the body tends to adapt to them and the aversive
may lose a certain amount (but often not all) of its effectiveness over
time, as a result. However, for other types of punishments, such as money
fines, this problem of adaptation does not occur.
All behaviors produce both some rewarding consequences and some punishing
consequences. The frequency of any behavior is the result of the net
combined effect of these rewards and punishments. When you stop using a
punisher, the behavior that formerly received the punishment tends to adjust
its frequency to whatever the net result that the remaining rewards and
punishments will produce. In other words, behaviors are always being
influenced by the total set of rewards and punishments that play upon them.
If you remove one punishment from the total set of rewards and punishments
that influence a behavior, the behavior adjusts its frequency to whatever
frequency the remaining set of rewards and punishments will generate.
For example, suppose a wealthy man routinely parks in a no-parking zone. He
may do this because the punishments that he receives for parking there
(perhaps some social disapproval and perhaps a minor parking fine, if he
gets caught) are outweighed by the rewards that a shorter walk to his
destination produces. Now suppose that we add a really stiff additional
money fine and/or that we place a "parking boot" on the wheel of his car
every time he parks in the no-parking zone. After we do that, we may find
that he stops parking in the no-parking zone, because the punishing effects
of losing a really large amount of money (and/or of removing the boot from
the wheel) now outweigh the rewards of parking closer to his destination.
But now suppose we discontinue this procedure of the added stiff fine and/or
the parking boot. At this point, the person may well start parking again in
the no-parking zone.
In this case the severe parking fine and/or parking boot (punishments) that
we added worked as effective punishers when they were added to the
situation; however, when they were removed, the person’s frequency of
parking in the restricted area changed back to the higher frequency that the
previous set of rewards and punishments had generated. In this sense, the
stiff fine and/or parking boot that we had added to the picture could be
said to have been only "temporary" in their effects. They were temporary
only in the sense that they worked for only as long as they were used.
Even though certain punishments may be only temporary in their effect, they
nonetheless have an important and valuable role to play in therapy. At JRC,
even if punishment suppresses a behavior only temporarily, this suppression
creates a "window of opportunity" during which, for the first time, it may
be possible to expose the student to certain rewards and educative
procedures which can turn his/her life around. For example, if we punish a
student for refusing to attend school and manage, by that procedure, to get
the student to come to school. Once that happens, the student may find that
he/she likes school, he/she may get "hooked" on the rewarding aspects of the
school, and may continue to come to school even after the punishment is no
longer given for refusals to attend. In this respect, punishment is a little
like training wheels. By its use, a student can start to enjoy biking on two
wheels and can start to develop the skills needed to keep in balance even
when the training wheels are removed.
The same thing is more or less true of rewards. When you add a reward
procedure into the set of determinants of a behavior, it may have an effect;
however, when you remove the reward, the behavior may well return to the
frequency level that the remaining conditions will generate. However, as in
the case of punishments, reward procedures, although only temporary in their
effect, can still be useful if they serve to open a "window of opportunity"
(like training wheels) to enable other factors to come into play, as was
explained above in the case of the punishment of a student for failing to go
to school.
So when the lady in question (with whom you had dinner) tells you again that
aversives are not effective in the long-term, you might want to ask her if
she knows of any reward procedures (or any drug procedures, for that matter)
that produce a permanent effect on the behaviors they are designed for --
i.e., that produce an effect that continues even after they are no longer
being applied.
Those who criticize aversives tend to support what they refer to as
positive programming. Such persons will tell you that there is no need
to employ aversives because you can effectively treat all special needs
children using only positive progamming. Postive programming means carrying
out education and treatment while using rewards together with only those
punishments that do not rise to the level of being called "aversives."
Proponents of positive programming tend to be quite willing to employ
psychotropic medication in their approach to treatment.
Because those opposed to the use of aversives have been successful in making
the use of aversives controversial, in recent years psychologists have
tended to avoid using or doing studies that use aversives. Those
psychologists who support positive programming have started their own
professional organization and journals and have significantly influenced the
policy of many state and national organizations.
By and large, those who espouse positive programming work with students
whose behaviors are much less severe than those we deal with at JRC.
Practically every single student who has been referred to JRC has received,
and failed to benefit from, positive programming prior to his or her
referral to JRC. And schools that employ only positive programming often
refer their difficult cases that do not respond to such programming, to JRC.
Now for some responses to the highlighted lines in the documents you sent to
me.
1.
What is the "Right to Effective Treatment?"
There have always been persons of good will
and good intentions who are strongly opposed to aversives. They oppose
aversives with the same passion and mission as those who strongly oppose the
use of animals in research (animal rights advocates) and the procedure of
abortion. A notable characteristic of those who oppose aversives, whom some
have termed the "anti-aversive advozealots," is that they are unwilling to
evaluate aversives by scientifically weighing their pros and cons, or by
evaluating their benefits against their risks. They believe that these
practices, regardless of what practical benefits they may give to
individuals or to mankind, are simply Wrong (with a capital "W")
philosophically.
Even if one were to point out the fact that the use of aversives treatment
procedures, as a supplement to other reward procedures, have saved persons’
lives that otherwise would have been lost (something that is clearly true),
that would not convince such persons to allow aversives to be used.
Conversely, even if the removal of aversives leads to a child’s death, that
would not be enough to convince them that there might be a legitimate place
for the careful, controlled judicious use of aversives in such severe cases.
In fact we had just such a case at JRC. A severe self-abusive student who
had come to us in a wheelchair had, with the help of aversives, as a
supplement to his program that was otherwise overwhelmingly positive in
nature, managed to stop his scratching and even attend public high school in
Attleboro Mass. However, the anti-aversive advozealots managed to convince
the young man’s mother to remove the student from our care and to allow her
son to be transferred to an anti-aversive service organization who placed
the young man in an apartment in Brooklyn that he shared with another
student. Within about 9 months I was reading the obituary of this young man
in the New York Times. He had scratched himself to death (the scratching had
led to blood poisoning and eventually, to paralysis). Nonetheless the
anti-aversive advozealots still claimed that they had "liberated" him from
JRC and to this day probably still believe that he represented a shining
example of the fact that handicapped persons can live a normal life and do
not have to be treated with aversives.
Behavior modification treatment that includes aversives is an alternative to
other approaches for dealing with persons with severe behavior problems. One
of these other approaches is to drug the individual so heavily with
psychotropic medication that he or she is half-asleep and less likely to be
aggressive. The advozealots appear to have no trouble with heavy use of
psychotropic medication. Another approach is to simply let the individual
vegetate. The philosophy of this approach is, "If we don’t bother students
by trying to educate them or by trying to change their behaviors, perhaps
they will not bother us by showing their most problematic behaviors." The
advozealots do not seem to have much trouble with this alternative, either.
No member of the Autism National Committee (which is the organization in
whose newsletter this first document appeared), has ever taken the
opportunity to visit JRC. It is little surprise, therefore, that there are
numerous errors of fact and/or omission in this document.
Here are some responses to the portions of the documents that you sent to me
that were highlighted.
"continued to treat students with disabilities with manacles…"
We do use wrist restraints with severely aggressive students, when required.
With such students they are safer and more effective than manual restraint.
"…Weeks and months of isolation…" We do not use isolation as
an aversive procedure or in any other way and have never used it.
"...up to 200 electroshock s a day...." Our program is
primarily based overwhelmingly on positive reward procedures. For a
description of our positive programming procedures, please
click here. We use aversives as follows: only with about 50% of
our population; only after we have tried positive-only programming and found
it to be insufficiently effective; only as a supplement to a program of
powerful, positive rewards that is probably unrivaled among residential
programs for special needs students; only with prior approval of the parent,
a physician, and of the Bristol County Probate Court; and only under a set
of comprehensive protections against abuse that include quality control
monitoring, a 24/7 digital video monitoring system, and human rights and
peer review oversight. For a detailed description of 13 safeguards we use to
insure careful use of aversive procedures, please
click here.
A new student entering JRC has only about a 30% chance of having aversives
used in his/her program during the time that he/she is a student at JRC. For
those students with whom we do use aversive procedures (only about one half
of our current population), the average student receives only 1-2
applications per week.
" which has been reported to cause burns on the skin of about a third
of the students…" Our skin shock device does not cause burns when it
is applied. Very, very occasionally, a device might cause a superficial mark
on the skin, from which the skin recovers quickly.
"…neither…Israel
or his school has ever submitted data on the success of any of these
therapies…" Our mission is to
function as a school, or service agency, and not as a research agency.
Indeed, the funds we receive for our services are not supposed to be spent
on research. It is required that they be spent on services. The use of
skin-shock in the treatment of severe problem behaviors is one of the most
widely published type of behavior modification papers in the literature.
Although every skin shock device is a little different, the fact is that
skin shock as a treatment procedure has been the subject of a great many
scientific publications. Today I would guess that there are approximately
120-150 published papers on this topic. We have published a
number of papers on this topic on our website, however.
The 1987 National Institutes of Health held a Consensus Conference on
Destructive Behaviors and their treatment. This conference which brought
together experts from all over the country, and which spent two years
reviewing the published literature, concluded that aversives have a
legitimate place in the treatment of severely destructive behavior. This was
a statement of what the published literature supported as legitimate
treatment procedures and it still stands as the most authoritative statement
by the professional community on the controversial topic of the use of
aversives. See
http://consensus.nih.gov/cons/075/075_statement.htm
The fact that in recent years the anti-aversive advozealots have managed to
get the NIH to add a disclaimer to the conference report saying that the
consensus report is not viewed as guidance for medical practice does not
detract from its value. The NIH Consensus Report never was intended as
guidance to physicians. It was simply a consensus statement, by a broad
group of respected professionals, of what the published scientific
literature, as distinct from the philosophical arguments of the
anti-aversive advozealots, supports.
"…punishment is neither necessary, nor more effective nor easier than
positive and humane alternatives..." There are, unfortunately, some
students whose problematic behaviors are so severe that positive positive
programming procedures alone may prove insufficiently effective to treat
their problematic behaviors. These are the types of students who get
referred to JRC. Currently we have over 230 of them from many different
states. As noted earlier, court-authorized aversives are employed with only
50% of our current students and with only 30% of incoming students.
It should also be noted: (1) that we accept the really difficult students,
with case-hardened aggressive and/or self-abusive behaviors, that public
schools refuse to handle and that other programs often refuse to accept and
refer, instead, to us; (2) that we proudly maintain a near-zero rate of
rejection and/or expulsion of students (no student is rejected or expelled
due to the severity of his/her behavior problems alone); (3) that we have a
policy of using no or absolutely minimal amounts of psychotropic medication;
and (4) that we do not "babysit" students, but require, instead, that they
engage in an active program of learning and behavior-changing. In other
words, it would be easy (and is easy in the case of some schools) to avoid
the use of aversives if one accepts only the easy-to-treat students, demands
next to nothing of them, and uses heavy amounts of psychotropic drugs to
medicate them instead of operating an active educational and treatment
program.
2. Cattle Prod Therapy: Aversive
Interventions
"Aversive interventions were phased out in
many institutions after they were found to have a poor effect on changing
behavior in the long run…"
The anti-aversive advozealots have been
successful in making the use of aversives seem to be "politically incorrect"
in many quarters. These opponents of aversives have managed to get
regulations adopted and even legislation passed in some states (including
Connecticut and California) that have prevented psychologists and others
from using aversives. In Massachusetts a bill has been introduced in almost
every legislative session to ban the use of aversives. The anti-aversives
advocates have been successful in making the use of aversives highly
controversial. I think that this is the reason why aversives are not used in
institutions. The reason is not that aversives have any particular deficit
in the area of "changing behavior in the long run."
3. Employment News advertisement for JRC
Staff
"...No experience is required for most
positions..." The reason for
this is simply that we provide our own pre-service and inservice training
program in how to carry out our treatment procedures. Our program is unique;
therefore it requires and its own staff training program. No amount of
experience in other settings would provide the training that we require our
staff receive before they are allowed to play a role in carrying out our
treatment systems.
4.
Behavioral Treatment Under Fire
"…Many state officials have been trying for
a decade to shut down the behavioral program…"
This is true. There have been two concerted attempts by state officials to
close JRC down, one in 1985 by the Massachusetts Office of Child Care
Services, and one in 1993 by the Massachusetts Department of Mental
Retardation. Each time our parents came to our defense. Each time the state
officials lost in court. On the most recent occasion, when former
Massachusetts Governor Weld read the judge’s decision and findings, he
called the Commissioner of the Department of Mental Retardation (DMR) into
his office and demanded and got his immediate resignation.
As a result of that lawsuit the licensing agency (DMR) that licenses our
residences was put into a receivership in which DMR’s power to license JRC
was taken over by a Receiver.
I hope this helps.
Sincerely,
Matthew" |