11/10/2019, by Julie Roberts, M.S., CCC-SLP
As a CCC-SLP, I successfully collaborate and/or co-treat with many professionals including occupational therapists, physical therapists, nurses, ENTs, physicians, educators and paraprofessionals, and music therapists. My primary clinical obligation, however, is to the clients or patients I serve, whether they happen to be a child or an adolescent, or an adult with an acquired language disorder secondary to a neurological event, or an elderly person with swallowing or cognitive decline or dementia. I have worked across all settings: Birth to 3, schools, in-patient, out-patient, pediatric clinic, home health, IRF, LTAC, SNF, Clinical Education, and Compliance in the past twenty years.
ASHA’s Code of Ethics tells its members that:
“The responsibility for the welfare of those being served remains with the certified individual. … Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.”
CCC-SLPs whose practices are focused on a neurodiversity model may question whether or not the intense drive for collaboration and IPP specifically between SLPs and BCBAs is an ethically mandated professional obligation by ASHA. Frequently, CCC-SLPs are reproached by peers for being “unethical” or for not “collaborating” as the SLP uses clinician autonomy to push back against perceived forced compliance for collaboration with a therapist whose practice uses an ABA-derived therapy model.
ABA practices will always be based upon a foundation of compliance, coercion, and behaviorist principles. It is impossible to practice ABA even gently or playfully, without attempting to control and manipulate a person’s behavior and/or violate their body autonomy. The fundamental goal of ABA is compliance to the will of the person in the position of authority; this is completely counter-intuitive to self-advocacy, self-determination, and upholding human rights and dignity.
ASHA tells its members that “Evidence-Based Practice (EBP) is the integration of:
· clinical expertise/expert opinion;
· external scientific evidence; and
· client/patient/caregiver perspectives.”
Throughout the entire process of evaluation, development of the plan of care, provision of therapy services and finally, discharge, my professional practice is to take the research framework from evidence-based medical, developmental and relationship-based therapy models, use my knowledge of client and caregiver perspectives, (which, specifically regarding ABA, come from The Autistic Self-Advocacy Network, The Autistic Cooperative, and multiple other actually autistic communities, as well as personally shared client and caregiver experiences), and then apply my extensive clinical background and knowledge to implement therapy practices which are evidence-based, respectful, culturally competent, trauma-sensitive and empathetic.
I have ethical and moral objections regarding the Association for Behavioral Analysis International’s (ABAI) refusal to condemn the Judge Rotenberg Center’s (JRC) use of aversive conditioning through painful and torturous shock therapy on its patients. In fact, ABAI featured the center at their 2019 conference. In fact, the United Nations called for an investigation of JRC’s shock treatments on June 5, 2019, where they called the practice torture.
Additionally, I find it reprehensible that the ABA model allows for the use of punishment, and offers guidance for exactly how to punish human beings through its code of ethics: 4.08 Considerations Regarding Punishment Procedures.
(a) Behavior analysts recommend reinforcement rather than punishment whenever possible.
(b) If punishment procedures are necessary, behavior analysts always include reinforcement procedures for alternative behavior in the behavior-change program.
(c) Before implementing punishment-based procedures, behavior analysts ensure that appropriate steps have been taken to implement reinforcement-based procedures unless the severity or dangerousness of the behavior necessitates immediate use of aversive procedures.
(d) Behavior analysts ensure that aversive procedures are accompanied by an increased level of training, supervision, and oversight. Behavior analysts must evaluate the effectiveness of aversive procedures in a timely manner and modify the behavior-change program if it is ineffective. Behavior analysts always include a plan to discontinue the use of aversive procedures when no longer needed.
In addition to speech-language pathology, my clinical knowledge and background include rehabilitation education, and healthcare ethics and compliance, having served as a national compliance director for the largest post-acute rehab company (at the time) in the U.S., as well as a regional clinical director. I have been a patient rights advocate throughout my career; and in the last three years, I have become a vocal patient/client rights activist. As a CCC-SLP, my personal and professional ethics, along with over 20 years of clinical experience, and shared client/patient/caregiver perspectives, indicate that ABA therapy methodologies and models do not respect dignity or self-determination, may cause trauma and often lack empathy because of mandatory compliance.
I have extensively researched and found other evidence-based practices with which to serve my clients. These therapy models respect dignity, self-determination, are empathetic and do not cause trauma.
Despite the claims of the ABA Industry, applied behavior analysis is not the “Gold Standard” for autism treatment. The U.S. government does not agree that ABA is the “gold standard” either. On October 25, 2019, they said that “the effectiveness of applied behavioral analysis for autism remains unproven.”
The Department of Education’s Office of Special Education Services does not believe that ABA is the “gold standard”. In fact, they are concerned that “a growing number of children with ASD may not be receiving needed speech and language services, and that speech-language pathologists and other appropriate professionals may not be included in evaluation and eligibility determinations under the Individuals With Disabilities Act (IDEA).”
CMS states that Medicaid covers services for autistic children, and specifies that benefit requirements do not name a specific treatment, but instead address a child’s individual needs.
Recently, “A large clinical trial of an applied behavior analysis (ABA)-based intervention for autism spectrum disorder shows the treatment might not be as advantageous as previously believed.”
SLPs who practice a neurodiversity model and who work with Autistic populations do not “treat autism.” We evaluate and treat communication disorders, provide barrier-free access to AAC and provide humane and ethical therapy for feeding difficulties and auditory processing issues. We do not suppress stimming or echolalia, force eye-contact, or require “whole body listening.” We do not steal childhoods from children via 20–40 hours of ABA per week. Autistic and other neurodivergent children deserve unstructured free time, just the same as neurotypical children.
If we are working with TBI, post-stroke or dementia patients in medical settings we do not violate patient rights(( §482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment.)) by coercing or manipulating our patients to comply through a system of reward and punishment.
We do not force compliance through the earning of snacks, checkmarks, behavior charts, stickers, or access to favorite items, activities or similar. We completely reject aversion therapy (punishment) for any situation, including withholding attention or affection, favored foods, activities or objects. We don’t train human beings like pigeons, chickens or dogs.
ASHA has guidelines in our ethics code for “collaboration” and “interpersonal professional practice” (IPP), which are two terms ABA practitioners often use in order to attempt to intimidate or gaslight both CCC-SLPs and ASHA into believing that speech-language pathologists are being unethical if we dare to voice negative opinions against the use of ABA practices and/or BCBA and RBT incompetency (as they dangerously or inadequately provide speech therapy services for which BCBAs and RBTs are not educated or trained).
ASHA’s Code of Ethics describes collaboration as: “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.”
ASHA Code of Ethics Effective March 1, 2016:
Individuals who hold the Certificate of Clinical Competence may delegate tasks related to the provision of clinical services to aides, assistants, technicians, support personnel, or any other persons only if those persons are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified individual.
Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, judgment, or credentials that are within the scope of their profession to aides, assistants, technicians, support personnel, or any nonprofessionals over whom they have supervisory responsibility.
BCBAs are not adequately prepared to address the following skilled services for which Speech-Language Pathologists are uniquely educated and trained:
•Assessment and intervention of language impairments in preschool and school-age children
•Motor speech disorders
•Neurogenic communication disorders
•Anatomy & Physiology of Speech & Hearing
•Childhood Apraxia of Speech
•Dysphagia in Public Schools
•Research in Pediatric TBI
•Tracheotomy and Mechanical Ventilation
•Articulation and Mechanical Ventilation
•Articulation and Phonological Disorders
•Counseling in Communication Disorders
•Neurogenic Communication Disorders
If an SLP is delegating tasks that require the unique skills, knowledge, judgment, or credentials of a speech-language pathologist to a BCBA or RBT, this is an ASHA ethics violation.
For example, SLP Assistants are not permitted to do feeding therapy because of potential harm to clients secondary to their lack of knowledge for dysphagia, pediatric feeding, and anatomy and physiology. Why in the world would we allow a BCBA or RBT to do so? More examples: Apraxia is not a behavior, it’s a motor speech disorder. A neurogenic condition is an injury or disease in the brain, it’s not a behavior. When we collaborate in areas where a BCBA or an RBT is not educated or trained, are we keeping paramount the best interests of those being served?
Remarkably, the BACB Code of Ethics doesn’t’ even include the words collaborate or collaboration in the code. What their code does say is:
“(b) When indicated and professionally appropriate, behavior analysts cooperate with other professionals, in a manner that is consistent with the philosophical assumptions and principles of behavior analysis, in order to effectively and appropriately serve their clients.”
Although they sound similar, the words cooperate and collaborate have subtle differences in meaning that are hugely important in this instance; as such, “cooperate” does not equate with “collaborate.”
• Collaboration is working together towards accomplishing a common goal.
• Cooperation is to work with other people to achieve one’s own goals as part of a common goal.
While SLP-BCBAs actively campaign to advance the cause of “collaboration” between SLPs and BCBAs as they propagate the mission for “ABA in all 50 states,” even they will privately admit that collaboration and cooperation are not identical. Furthermore, collaboration between an SLP and a BCBA (or RBT) does not mean that the SLP teaches the BCBA or RBT to target areas outside the BCBA scope of practice, such as pragmatic language, language development, swallowing and feeding, articulation and phonological processing, apraxia, aphasia, and echolalia.
Regarding ASHA’s Ethical Guidelines on Social Media: It is not an ethical violation to voice an opposing opinion on therapy methodologies and models:
“Can the Inappropriate Use of Social Media Constitute an Ethical Violation?
Yes, under some circumstances, the inappropriate use of social media may lead to ethical violations under the Code. Examples of this include (a) posting distinctive personal information about your clients or research subjects that breaches confidentiality and (b) misrepresenting to the public the services you provide, the products you sell, or your level of expertise. The Code is usually not violated, however, when individuals post insulting or offensive opinions, even though doing so is failing to engage in civil discourse. The Code is not a civility code. Rather, the Code is “a framework and focused guide for professionals in support of day-to-day decision making related to professional conduct”; and the “Rules of Ethics are specific statements of minimally acceptable as well as unacceptable professional conduct.”
ASHA tells us that: “IPE is an activity that occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve outcomes for individuals and families whom we serve. Similarly, IPP occurs when multiple service providers from different professional backgrounds provide comprehensive healthcare or educational services by working with individuals and their families, caregivers, and communities- to deliver the highest quality of care across settings.”
SLPs who practice a neurodiversity model cannot ethically ignore client/patient/caregiver perspectives that the outcomes of ABA include trauma and lowered self-esteem because of forced compliance and masking. ABA is abusive. SLPs cannot dismiss the client/patient/caregiver perspectives that warn that ABA is disrespectful of dignity, autonomy and self-determination.
In summary, CCC-SLPs and BCBAs – “Keeping paramount the best interests of those being served,” please be aware that ASHA’s Code of Ethics does not arbitrarily mandate that CCC-SLPs collaborate or cooperate with a professional or an industry in a manner “consistent with the philosophical assumptions and principles of behavior analysis,” if the CCC-SLP’s clinical expertise and expert opinion determine:
a) that the client/patient requires the unique skills, knowledge, judgment, or credentials of a speech-language pathologist, or
b) that the methodologies and/or therapy models do not respect the dignity of the client or patient, could cause them trauma, or could be construed as abusive or as lacking in empathy.
On Collaboration and IPP: This is a professional autonomy issue.
This is an ethics issue, a civil liberties issue, a human rights issue.
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