Foucault, Neuro-Diversity and Applied Behavioural Analysis

“An experiment with a panoptic  system would suffice to find out;  different things could be taught to different children in different cells;  we could teach no matter what to no matter which child, and we would see the result. In this way we could raise children in completely different systems, or even systems incompatible with each other; some would be taught the Newtonian system, and then others would be got to believe that the moon was made of cheese. When they were eighteen or twenty, they would be put together to discuss the question” (Psychiatric Power p. 78)

When one reads the words of Foucault describing Bentham’s imagined Panoptic System  one thinks of Applied Behavioural Analysis (henceforth ABA). Bentham of course was one of the fathers of utilitarianism and ABA seems to implicitly adopt the approach a utilitarian approach to ethics e.g. a cost/benefit calculation. When one reads about Bentham’s tightly controlled environment with bodies under constant observation and control one is put to mind of ABA practitioners following around clients with clickers recording behaviour x or y and trying to change the contingencies of reinforcement.

Bentham, of course meant his Panoptic System as a positive way of achieving control and hence decreasing violence and suffering in prisons, and he felt that the Panoptic system would be useful in hospitals, schools etc. Foucault on the other hand saw the Panopticon as a tool of oppression used to gain control over people’s bodies. He viewed psychiatric power as typically operating implicitly to gain control of the bodies of others:

“It seems to me that generally, and here again in a particularly subtle, clever form, Leuret provided the formula of something very important in the system of psychiatric treatment of the time. Basically it involves establishing the patient in a carefully maintained state of deprivation: the patient’ existence must be kept just below a certain average level…The interesting thing about this is that this work is not just imposed because it is a factor in order, discipline and regularity but because it enables one to slip in a system of reward. Asylum work is not free; it is paid, and this payment is not a supplementary favour but at the very heart of the function of work, for the remuneration must be sufficient to satisfy certain needs creation created by the underlying asylum deprivation: insufficient food, absence of extras (tobacco, a dessert, etcetera, must be paid for). For the system of remuneration imposed with work to function, one has to have wanted, to have needed, and to be deprived. So, these remunerations must be sufficient to satisfy the needs created by the basic deprivation and, at the same time, sufficiently low to remain below, of course, normal and general remunerations.” (ibid. p. 153-155)

Again there are some parallels to ABA where when a child is being trained to behave in a particular way x a system of reinforcements are put in place. Food is typically a good reinforcer and it works best as a reinforcer when the child is hungry so it is best to try to implement the reinforcement schedule when the child is slightly hungry. So here we see a system similar to the one Foucault mentions where a state of deprivation is used to help shape the behaviour of a particular subject. Though there are parallels between Foucault’s description of psychiatric power and the behaviour of ABA practitioners; Foucault never actually discussed ABA as a treatment. In recent times however, ABA has come under fire by a variety of different schools of thought for being an unethical and coercive practice.

ABA is the most successful treatment we have for helping people with Autism and/or intellectual disabilities achieve functional communication and manage challenging behaviour. ABA is rigorously tested and is proven to work better than its rivals; yet it has its critics. There are those who oppose it strongly because of its use of punishment (for example mild shocks), some of these critics do not think such punishment is ever justified even if it can be shown to be the lesser of two evils. If it were shown that the use of mild shocks could help a child stop engaging in life threatening self-injurious behaviour some critics argue that this still would not justify the use of any kind of punishment.

Other critics argue from the point of view of neuro-diversity claiming that ABA is a form of coercion which tries to mould children into societal norms taking away the child’s unique way of experiencing the world. The neuro-diversity movement argue that neuro-typical people use the fact that they exist in greater numbers, and the fact that they have greater power, to try and force people with different kinds of mind to conform to this social pattern. In these circles, ABA is sometimes portrayed as the enemy which is most responsible for this coercion.

Critics from a neuro-diversity perspective and critics of the use of punishment are not arguing that ABA is not successful on its own terms rather they are arguing that the treatment should not be used because of ethical concerns. Claims like these are in the normative domain and proponents on both sides of the dispute sometimes do not make clear their underlying philosophical assumptions which guide their differing intuitions on the ethical status of ABA. This isn’t helped by the practice of behavioural analysts when discussing ethics pretending their underlying philosophical positions do not exist:

“Although the Code of Ethics for Behavior Analysts has been around for some time, where the present volume makes its strongest contribution is in its formulation of over 100 case descriptions of practice situations requiring the application of the pristine statements found in the Code of Ethics into real life contexts. These case descriptions cover the spectrum of behavior analytic practice, and the exegesis accompanying these illustrations is elegant, sparse (in the laudable parsimonious sense), and understandable. There is no discussion of lofty theoretical principles pertaining to ethical decision making, and in my view this is a good thing.” ( Review of Ethics for Behavioral Analysis p. 148)

The above attitude invariably leads one into trouble when debating on ethical issues; as Dan Dennett has correctly noted, there is no such thing as philosophy free science but rather science which uses unexamined philosophical baggage. In a debate between Foucault and people like Bentham it is clear what the underlying philosophies are and the merits of each philosophy can be argued about looking at the pros and cons of each system. This avoids mere question-begging and merely assuming that one’s system is superior and ignoring the alternative system. But when ABA defenders argue with their critics there is some times not enough consideration given as to whether the ethical assumptions they are making are justified. parsimonious sense), and understandable.There is no discussion of lofty theoretical principles pertaining to ethical decision making, and in my view this is a virtue.” (‘A Review of Ethics for Behaviour Analysts’ Baily and Burch p. 148) parsimonious sense), and understandable.There is no discussion of lofty theoretical principles pertaining to ethical decision making, and in my view this is a virtue.” (‘A Review of Ethics for Behaviour Analysts’ Baily and Burch p. 148 parsimonious sense), and understandable.There is no discussion of lofty theoretical principles pertaining to ethical decision making, and in my view this is a virtue.” (‘A Review of Ethics for Behaviour Analysts’ Baily and Burch p. 148)

In a recent exchange in the Facebook group ‘ABA Ireland’ a critic of ABA and a defender of ABA were having a heated discussion on the ethical status of ABA. The defender of ABA argued that the use of mild punishment is sometimes justified because this punishment would decrease negative, possibly life threatening behaviour. For a behaviour analyst there is a responsibility to try and decrease negative behaviour with non-punishing procedures such as positive or negative reinforcement; however punishment is justified in cases where neither positive nor negative reinforcement is likely to work. A behaviour analyst will have to justify claims about the likelihood of punishment decreasing certain more damaging behaviours in an objective manner. What should be obvious to anyone with a bit of philosophical training is that behaviour analysts are using a type of utilitarian calculus to justify their interventions. Utilitarianism is well respected philosophical position on ethics, one that is highly worked out and sophisticated. Nonetheless, it should be acknowledged that utilitarianism is just one philosophical position amongst others; its chief rival being Deontology. Now while thinkers like Sam Harris have tried to repackage utilitarianism as the scientific position on ethics few people have taken him seriously. The reason being that Harris simply assumes from the outset that utilitarianism is the best way to judge what is or is not ethical and hence he is guilty of simply begging the question against his opponents who do not accept his starting point. When behavioural analysts debate with critics of ABA they typically begin with the assumption that utilitarianism is the correct way to judge ethical issues; though they typically don’t state this, if their interlocutor doesn’t accept this unstated assumption then a lot of talking past each other occurs. In these debates it would be better to perhaps discuss the types of ethical systems that they are subscribing to and judge the validity of these ethical systems before jumping straight into first order debates.

In the discussion I mentioned above one of the critics of ABA  replied angrily to the admin that no matter what way you look at it ABA involves coercion; he seemed to think that coercion or control of any kind was intrinsically bad. Now with competing philosophies like the defender of ABA’s utilitarianism or the ABA critics seeming to appeal to some kind of categorical imperative e.g. “coercion is always intrinsically a bad thing to engage in even if it has pragmatic justification” we will need to move the debate up a notch or two to see if we can gain any traction in the debate. But this is not typically done in such discussions.

Because philosophical positions aren’t clearly staked out in some discussions does not mean that ABA practitioners do not take ethics and their duty of care seriously. There is a massive literature on ABA ethical practice and a variety of different sources are used to ascertain what the best course of action to take on a given occasion is:

“In cases in which withholding or implementing treatment involves potential risk, Peer Review Committees and Human Rights Committees play distinct roles in protecting client welfare. Peer Review Committees, comprised of experts in behaviour analysis, impose professional standards to determine the clinical propriety of treatment programs. Human Rights Committees, comprised of consumers, advocates, and other interested citizens, impose community standards to determine the acceptability of programs and the extent to which a program compromises an individual’s basic rights to dignity, privacy, and humane care; appropriate education and training; prompt medical treatment; access to personal possessions, social interaction, and physical exercise; humane discipline; and physical examination prior to the initiation of a program that may affect or be affected by an individual’s health status. Professional competence aided by peer and human rights review will ensure that behavioural treatment is delivered within a context of concern for client welfare.” ( Ron Von Houton et al p.323 )

Above we can see the meticulous attention to detail and a real concern for client welfare. An important point to note are that one of their major sources of ethical advice given to ABA practitioners is from peers who accept the same roughly utilitarian ethic that is common for ABA practitioners. So these peer review committees will not satisfy people who do not accept the working assumptions of ABA practitioners e.g. members of the neuro-diversity community.  In the 2013 book ‘Ethics and Neuro-Diversity’ C D Herrera argues that one man’s “objectionable symptom” is another man’s positive trait or ability or a sign of uniqueness to be cherished. So he clearly won’t be happy with a utilitarian ethics which supposedly focuses on changing “symptoms” as opposed to cherishing a person’s unique way of being in the world.  The other source of information comes from Human Rights Committees, which consist of concerned citizens, advocates etc are supposed to provide a community standard from which to judge the ethical standards of the treatment. But given the diverse views on ethics that different communities have one struggles to see whether ABA proponents are proposing a type of relativism where each community has its right to impose its own idiosyncratic standards or whether they think all communities will invariably end up championing the same ethical system. Psychologist Susan Friedman has discussed the importance of social standards being considered in her paper ‘What’s Wrong With This Picture: Effectiveness is Not Enough’. She argues as follows:

“Within the field of applied behaviour analysis, there is a 40-year-old standard that promotes the most positive, least intrusive behaviour reduction procedures (also known as the least restrictive behaviour intervention, LRBI). This standard is upheld in public federal law protecting children (IDEA, 1997), and the Guidelines for Responsible Conduct for Behaviour Analysts (Behaviour Analyst Certification Board, 2004). According to this federal and professional standard, procedures with aversive stimuli are more intrusive and would be recommended only after less intrusive procedures have been tried.” (Friedman ‘What’s Wrong With this Picture: Effectiveness is Not Enough’ p. 2)

She notes that effectiveness is an important criterion to use to judge whether a particular treatment should be implemented. However, she notes that effectiveness alone is not sufficient; we also need to factor in Social Acceptability. On the issue of social acceptability, or what she at other times calls humaneness, she thinks of paramount importance is selecting the technique which is least intrusive and most effective. This is a key ethical consideration in ABA and involves using things like functional analyses to assess our ABCs (Antecedent-Behaviour-Consequence) if we can discover that a particular behaviour is typically caused by a particular antecedent (e.g. screaming is always preceded by being in a noisy environment) we can change the antecedent without engaging with an intrusive reinforcement programme. If we cannot change the behaviour by changing the antecedent we will use some kind of reinforcement schedule (either positive or negative) to try to extinguish the behaviour (while factoring in dangers like extinction bursts), if this is not effective negative punishment may be used. A last case scenario is positive punishment. And with positive punishment only certain types of punishments are permitted such as mild shocks in extreme cases. In cases where mild shocks are implemented it needs to be established that other less invasive techniques will not work. And any such treatment will be assessed using assessment from peer committees, and human rights committees will have to be consulted.

The use of stronger than mild shocks; shocks that could cause real suffering to people using behavioural analysis will not be permitted. Friedman appeals to social acceptability/humaneness effect as a reliable way of avoiding the use of such severe punishments. And by and large we have societal laws, and societal norms, that prohibit such unwarranted behaviour. Behavioural analysts working with their own code of ethics, and those of the society they work within, should by and large avoid the use of what we would consider excess punishment.

However it is important to note that societal laws and norms change over time and vary widely. Different cultures vary widely on what they accept as moral or immoral behaviour. Furthermore particular cultures values change over time to the point where from the vantage of contemporary moral standards past behaviour of our culture may seem barbaric (e.g. Women not being allowed to vote, Slavery being acceptable etc.). Steven Pinker’s book ‘The Better Angel’s of our Nature’ attempts to evaluate our propensity for violence and attitudes towards violence from hunter gather times up until today.  Pinker has had a lot of criticism about his accuracy in describing the lifestyles of hunter gathers; but most scholars agree that his description of the changes in levels of violence throughout the period from when humans began domesticating animals,  to the industrial revolution up until the present time is pretty accurate. Pinker establishes a shocking picture of how human attitudes towards violence have changed throughout history.

Anthropologists are forever discovering different attitudes towards morality in different cultures. With these variations in culture and history one wonders how ABA practitioners can cope with these differences. If human rights committees in different cultures have different standards of ethics; then what is the response of ABA practitioners to be? Use different types of punishments depending on the culture they are practicing in? Or hold with fixed ABA ethical principles and refuse to operate in countries which don’t meet these standards. I prefer the second option; though it is not without its problems it is strange that Friedman doesn’t seem to even contemplate let alone try to solve ethical conundrums related to cultural differences.

Difficulties with dealing with supposed community consensus aside defenders of ABA don’t really consider any real objections to their utilitarian position. In his blog-post ‘On Ethics part 2 Massimo Pigliucci’s  considers a variety of criticisms of utilitarianism: (1) There are alternative ways of working out the utilitarian calculus and there is no logical way to distinguish between them (2) It does damage to our intuitions e.g. it tells us that our children’s happiness count for no more than a strangers does. (3) It is very difficult to decide what the overall consequence of an action is; what exactly is the scope of ‘OVERALL’ the entire set of events till the universe dies? (4) It has problems with rights e.g. the harvesting of organs of one healthy person to save four dying people[1]. Pigliucci’s list is by no means exhaustive and contemporary utilitarians have replies of various qualities to the above criticisms. Again one is left wondering how ABA ethicists don’t even seem to consider objections to utilitarianism in their ethical discussions. It seems that a lot of them are guilty of taking on board philosophical baggage without examining it thoroughly.

Connected with this issue is a strange reliance on the notion of rights in considerations of their ethical approach. The notion of rights loom heavy in Van Houton et al’s paper ‘The Right to Effective Behavioural Treatment’:

 “Improvement of functioning may take several forms. First, it often will require the acquisition, maintenance, or generalization of behaviours that allow the individual to gain wider access to preferred materials, activities, or social interaction. Second, it may require the acquisition of behaviours that allow the individual to terminate or reduce unpleasant sources of stimulation. Third, improved functioning may require the reduction or elimination of certain behaviours that are dangerous or that in some way serve as barriers to further independence or social acceptability. Finally, as a member of society at large, an individual has a right to services that will assist in the development of behaviour beneficial to that society…Indeed, a slow-acting but non restrictive procedure could be considered highly restrictive if prolonged treatment increases risk, significantly inhibits or prevents participation in needed training programs, delays entry into a more optimal social or living environment, or leads to adaptation and the eventual use of a more restrictive procedure. Thus, in some cases, a client’s right to effective treatment may dictate the immediate use of quicker acting, but temporarily more restrictive, procedures. (Von Houton et al p. 383)

 

As can be seen above Van Houton et al seem to argue for a notion of human rights. Throughout the paper they list 6 basic human rights which should inform any behavioural intervention:

  1. An individual has a right to a therapeutic environment.
  2. An individual has a right to services whose overriding goal is personal welfare.
  3. An individual has a right to treatment by a competent behavioural analyst.
  4. An individual has a right to programs that teach functional skills.
  5. An individual has a right to behavioural assessment and ongoing evaluation.
  6. An individual has a right to the most effective treatment procedures available. (Van Houton et al pp 381-384)Rights based approaches to ethics are typically the area defended by deontologists. Thus a thought experiment typically used to point some unintuitive approaches to utilitarianism is the Famous Trolley Problem. The problem has many guises the simplest one is the fat man version. You are standing on a bridge and you see a train below you hurtling towards five people who are tied on the track below. There is a fat man standing beside you who you could push off the bridge and because of his great bulk you know he will stop the train when the train hits him. So do you push him over the bridge? By doing so you will save the lives of five people even thought you will be killing one. On a simple cost benefit calculus you kill the fat man. But most people react that killing the poor fat man is unjustified as the poor fat man has a RIGHT to decide if he wants to be sacrificed to save the people below him[2].            I suspect that when the bugs are worked out what will remain is a kind of loose pragmatism. This loose pragmatism is best to deal with disputes with people of the neuro-diversity movement. When neuro-diversity proponents defend the right to have a different way of being they have a point when it comes to those who are high-functioning. But from a point of view of children who are low functioning and engaging in self injurious behaviour there is little alternative but to apply the techniques of ABA (the only techniques we have that work). However when defenders of neuro-diversity argue that any technique that causes pain should be banned it is at this point that a switch to meta-levels of discussing overall ethical theories and the arguments pro or con these theories is the best approach. Merely begging the question against each other and assuming ethical systems are correct will lead to nowhere.
  7.             Now what is interesting is that ABA practitioner’s seem to want to defend a type of utilitarianism at the same time as defending a rights based approach. These approaches are not necessarily inconsistent (see for example the work of Thomas Scanlon) but it takes a lot of work to make them work in tandem. ABA practitioners seem to operate a utilitarian type view when working on their own peer review system and a rights based approach when dealing with what Friedman called the social acceptability of humane factor. This marriage is not as I have argued above an entirely happy one and it is one where there is scope ABA practitioners to make their overall views more explicit.
  8.  

[1] Pigliucci’s list is actually directed against consequentialism but they go through against utilitarianism as well.

[2] Interestingly philosopher Joshua Green discovered that psychopaths typically take the sacrifice the fat man approach. Note this obviously doesn’t prove that utilitarians are psychopaths.

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