The general belief in professionals dealing with non-verbal people with diagnoses of severe mental retardation has been that in general these people do not have the ability to spell, and (depending on the severity of the condition) perhaps not the ability to use language. As Jacobson (1993) puts it,
...if five years ago... educators had been presented with a videotape of a non-verbal person with autism and severe mental retardation co-actively typing out words on a computer keyboard with a staff member. ...What attribution would have been most likely if they had previously been given full information about the personís developmental and educational history that was entirely consistent with the presence of lifelong severe disability? I suggest that the most common attribution would have been that the staff member was influencing the content of the typing, and the more sophisticated the content of the typing, the more likely this attribution would be. (Jacobson, 1993, p. 17)
Jacobson asks
Why, then, should it be that our bias could have shifted so dramatically in so short a time [after] ...introduction of the FC [Facilitated Communication] ethos through continuing education? . (Jacobson, 1993, p. 17)
The question of whose biases, if any, were shifted during those years throws some light on questions concerning the construction and defence of professional attitudes.
Facilitated communication training (FCT) is an educational technique intended to allow people who cannot speak or sign to access communication devices. One person (the facilitator) provides support to the arm, wrist or hand of another person (the student) who is thus enabled to control their pointing sufficiently to point to pictures, words or letters.(Biklen, 1990; Crossley & Remington-Gurney, 1992). The method was developed in Australia by Rosemary Crossley and popularised in the United States by Douglas Biklen. It has recently been the subject of considerable debate by parents, therapists, care workers, and psychologists, and has a rapidly expanding bibliography. Both advocates and critics of the method agree on its importance; the former have suggested that
We now need to begin the task of restructuring our own view of people with autism and other developmental disorders, as well as the low-track education system into which they have been placed. A complete paradigm shift is underway. (Berger, 1992, p.5)
and the latter that
If the rhetoric and media hype promoting "Facilitated Communication" continues, it may well succeed in setting autism services back 40 years. (Schopler, 1992, p.337)
Disputes centre both on individual cases and on the general issue of whether the method can be used, as its critics suggest, at best only by very few atypical cases (Schopler, 1992) or, as its proponents suggest, by up to 70% of the communication-disabled population (Crossley & Remington-Gurney, 1992). This communication-disabled group overlaps considerably with the population diagnosed as severely intellectually disabled. Most individuals with severe communication impairments are labelled as intellectually impaired, and when one considers the dependence of the Diagnostic and Statistical Manual of Mental Disorders (APS, 1980) on expressive language skills this is not surprising. In a statewide survey in Victoria, Australia, 71% of those with SCI had been diagnosed as intellectually impaired (Bloomberg & Johnson, 1990).
It is suggested by proponents of the method that the majority of people with SCI regarded as intellectually disabled or mentally retarded may in fact have intact language comprehension but have also a variety of expressive language disorders that prevent its expression; that the underlying language malfunction in people with autism and developmental disability using FCT is not due to ìSignificantly subaverage general intellectual functioningî but to an expressive disorder, being some form of motor planning problem (Crossley, 1993) or apraxia (Biklen, 1990) or dyspraxia (Maurer, 1992) or movement disorder (Hill & Leary, 1992) coupled with aphasia or word-finding problems (Crossley, 1992).
Crossley and Biklenís theory would suggest that there has in the past been confusion between the peripheral symptoms of autism and developmental disorders and their core content. ó that when, for example, Howlin & Rutter (1987) say that
The [autistic] childís understanding of social language is usually markedly reduced, and a lack of symbolic gesture or mime is equally characteristic. ... Even very simple gestures, such as pointing, are affected, and if autistic children do indicate their needs in this way it is usually with the hand rather than with the extended index finger (Howlin & Rutter, 1987, p. qq)
the authors are describing an observed hand function problem and an observed problem in expressive language and linking that with a hypothesised internal language deficit. An alternative approach, Crossley suggests, might be to consider the possibility that the problem is not that when people have disturbances of language skills this also affects their motoric achievements, such as pointing, but that, conversely, that some people's motor disturbances may impair their speech and hand skills and thus affect their ability to relate to other people.
If true, the claims of the proponents of FCT would imply that the almost the entire psychological profession had been for its entire history radically mistaken about the nature of a basic element of its intellectual cosmology. As such, the debate about FCT can be taken as an example of the response of a profession to a major threat ó what one critic of FCT refers to as ìinappropriate challenges to professional belief systemsî. (Shane, 1993).
Some reputable psychologists , working for the most part in the field of autism, defend FCT (Donellan, 1992; Maurer, 1992), and some of its most active critics, such as Howard Shane, are not psychologists (Shane, 1993). However, the bulk of professional critics appear to be psychologists, and the bulk of professional adherents appear to be therapists and educationalists; taking the 90 authors of 89 academic or professional journal articles on FCT , in the 24 articles expressing negative conclusions about FCT 13 of the authors are psychologists, 11 are not, and the affiliations of 4 are unknown, while of the authors of the 45 articles expressing more positive conclusions the proportions are 3 psychologists to 37 others and 2 unknown, and of the 20 inconclusive articles 4, 15, and 1. One psychologist has expressed the view that psychologists are leading the ranks of critics because they have the scientific training ó the understanding of statistics and experimental methodology ó that others in the field of developmental disabilities lack (Cummins, 1991), and most critics are united in seeing the roots of the popularity of FCT in this lack of scientific rigor among non-psychologists.
Western societies, including the United States, have a relatively low level of scientific literacy... much of the scientific literature on topics such as autism... is fairly inaccessible to most people, including some educators and other professionals. (Jacobson, 1993, p. 17)
The dispute is also sometimes conceptualised as between qualitative research, as favoured by advocates for FCT, and quantitative (or ëexperimentalí, or ëscientificí) as favoured by its opponents. Professor Biklen, the originator of the American FCT movement, was already an active proponent of qualitative methodology when first introduced to FCT in Australia, and followed it in his own research.
This sturdy was accomplished by means of the qualitative research methods of participant observation... (Biklen, 1992, p. 8)
A similar approach is taken by Donellan (1993). Jacobson et al. criticise these methods on the grounds that
... proponents of FC tend to cite these arguments in anecdotal fashion, ignoring basic rules of scientific proof by using imprecise or undefined terms, unconfirmed observation, self-report by untrained individuals, and numerous idiosyncratic references to single cases. (Jacobson et al, 1993, p. 16)
Biklen has commented that characterization of the validation evidence he provides as ëanecdotalí
...trivializes qualitative field research methods. ...Our analyses of the field research data have been conducted within the tradition of qualitative research and grounded theory... Although this tradition may not be widely used in the fields of autism and communication, it is widely recognized in the social sciences, including education. (Biklen, 1992)
Opponents insist, however, that
It is folly to argue that qualitative research alone can reveal either the causes of disorders like autism and mental retardation, or the most effective methods for treating them.(Green & Shane, 1994)
Critics rely instead on ëcontrolledí experiments (and do not regard qualitative studies as ëexperimentalí). The most common format is for the user and the facilitator to be exposed to stimuli that are sometimes the same and sometimes different and asked to describe them through facilitation. A number of experiments (Hudson et al, 1993; Klewe, 1993; Moore et al, 1993; Szempruch & Jacobson, 1993; Wheeler et al, 1993) have recorded that in this situation the responses given are those sometimes appropriate to the facilitator, not the user. Some similar experimental studies (Calculator & Singer, 1992; IDRP, 1989; QDFSAIA, 1993; Vázquez, in press) have also reported successful validation of communication, and both camps have made objections to the format of the otherís tests (Hudson, 1994; Crossley, 1994).
The arguments have also been aired on several television programs and in a number of court cases regarding sexual abuse.
From the point of view of most critics of FCT, however, the problem is not how to refute the arguments of its proponents; the inadequacy of these, however apparently convincing, is taken as given -
Those who have the responsibility to make decisions concerning the use of FC should be especially wary of superficially reasoned rhetoric... (Jacobson, 1992, p.25)
and the real problem thus becomes how to account for the popularity of an obvious quack remedy. More specifically, the enthusiasm for FCT among different groups requires a number of different explanations. The most basic approach is that applied to statements claimed to have been made by persons using FC. Shane, for example, originally put forward as an important prop of his disbelief in the method that
Not one alleged competent user of the technique has come forward to prove the technique is genuine. (Shane, 1993, p. 13)
An article published over the name of Anne McDonald, a purported user, objected, giving details of validation trials Ms McDonaldís communication had undergone successfully in the course of a series of Australian court cases. Shaneís response did not comment on any of the material adduced as evidence of valid communication, resting instead on a more basic exclusionary principle.
In light of my conclusions in the paper FC; Facilitated or ëFactitiousí Communication, it would be illogical to direct a response to Anne McDonald. (Shane, 1993, p. 10)
This would seem a particularly effective Catch-22; the method cannot be validated unless users come forward to prove it, and proof presented by users cannot be entertained because the method has not yet been validated. Even without this catch, however, statements made by people with disability speaking for themselves can amount at best to ëself-reportí or ëcase studiesí, both traditionally suspect methodologies when not confirmed by experimental psychological studies.
Similarly, enthusiasm by parents of people with developmental disabilities for the technique is not a serious source of theoretical concern. The opinions and observations of parents are not usually regarded highly by professionals, and explanations that would justify setting them aside are readily available. Prior and Cummins point out that
Parents of children with a handicap as severe as autism can be particularly vulnerable to promises of a breakthrough to normality... (Prior and Cummins, 1992, p. 332)
More specifically, Mulick et al note that
Denial, a form of avoidant coping, is recognized as a common reaction to the diagnosis of... a disability in... a loved one (Mulick et al, 1993, p. 271)
A therapy that suggests the possibility of unimpaired intelligence has, it is suggested, a direct appeal to parents who are in denial regarding the reality of their childís disability. The testimony of parents is thus seen as having little independent weight and can be regarded as reliable only where confirmed, replicated, and published by professionals.
The problem for critics of facilitated communication training, however, is that the professions did not at first seem to be united in their opposition. In the United States, at least, many speech-language pathologists and special educators took FCT up with enthusiasm. While the errors of parents are predictable, different explanatory techniques are required to account for the concurrence in error of other professional groups. Schopler complains that
...the ideologues promoting ìFacilitated Communicationî use an especially pernicious form of sales technique... even at some of our university education departments. (Schopler, 1992, p. 337)
Jacobson et al state that
The growing deprofessionalisation of direct service provision in ìcommunitizedî and ìintegratedî settings has resulted in few voices at the level of program planning and direct service delivery who can evaluate treatment alternatives according to scientific criteria. (Jacobson et al, 1992, p. 27)
They suggest therefore that there is a
... growing vulnerability of consumers and paraprofessionals to pseudoscientific intervention strategies...(Jacobson et al, 1992, p. 27)
Jacobson & Mulick note that
acceptance of new therapies seems to be more rapid among students and agency-based non-licensed clinicians than among academics and licensed clinicians. ...students are more likely to be credulous. ...students can expect to be more effective clinicians than their mentors.... Direct service clinicians can expect to have a visible effect on the people they serve and get more respect from their peers. .... Administrators and managers can rest assured that their philosophy is new and improved. (Jacobson & Mulick, 1992, p. 3)
The fact that explanations of this sort are required, however, emphasizes that a significant number of professionals and paraprofessionals are on this matter resisting the direction of psychologists. Another article (Mulick et al) complains that
Speech pathologists are prominent in the clinical promotion of FC, especially via fee-for-service introduction of the basic procedures... (Mulick et al, 1993, p. 274)
condemns
philosophically inclined therapists and teachers with Masterís degrees... (Mulick et al, 1993, p. 275)
and complains that
Very little criticism has been voiced within developmental disability services... Many seem to view FC as the greatest breakthrough of all time... there has not been an aggressive and visible reaction by professional and scientific societies in medicine... and neuroscience...(Mulick et al, 1993, p. 278)
Mulick et al put this down to timidity on the part of the human services and apathy on the part of the neurosciences, but the unusual isolation of psychologists on this matter does draw attention to the potential in FCT for a major shift of professional turf. If autism, still more ëintellectual disabilityí is, as suggested by the advocates for FCT, in large measure a communication disorder, and that communication disorder arises out of a neurological disorder, then one of the obvious consequences of this would be that primary expertise in the field would cease to lie with the psychological profession and would move elsewhere, perhaps to the specialities of speech-language pathology and neurology. Jacobson (1993) notes some the difficulties such a contest would involve.
In Western society there is also a bias to consider neurological or biological explanations of human behaviour to be superior or more fundamental explanations than those arising from the behavioural or social sciences. (Jacobson, 1993, p. 17)
A further complication is that, as the quotations from Jacobson & Mulick (1992) on ëcommunitizationí and Mulick et al (1993) on ëphilosophically inclined therapistsí suggest, some of the tensions between advocates and critics of FCT have been carried over from previous disputes within the professions over such things as the value of community living. Advocates are drawn disproportionately from the deinstitutionalization movement, critics from its opponents. Rimland attacks Biklen both for his support of facilitated communication training (Rimland, 1992) and for his advocacy of inclusive education (Rimland, 1993) and deinstitutionalization (Rimland, 1993).
The people who wrought such harm on the institutionalized mentally ill are still at work. Now they are destroying the institutions needed for the most severely retarded and autistic people. .... The PC people are trying to brainwash us into believing, as they seem to, that there is no real difference between the mentally handicapped and the rest of us, but there is. ... Biklenís ideas are specious. ... How do we combat these seductive but pernicious ideas? (Rimland, 1993, p. 2)
The popularity of Biklenís theories on community integration for people with disabilities is linked with his advocacy of FCT, which is generally seen by psychologists as a morbid symptom in society. The various explanations advanced to account for the popularity of FCT are also applicable to the perceived vogue for changes in the communityís management of intellectual disability. The attack on FCT is in fact seen by both sides as a lever that may possibly throw into reverse the trends towards community integration, and the attacks on FCT have been criticised for this reason by disability advocacy groups such as The Association for Severe Handicap that are not yet prepared to endorse the method itself.
Describing Facilitated Communication Training as a threat to the psychological profession does not, of course, suggest that the profession is actually facing overthrow. Psychology is a good deal better defended than that, and is capable of repelling stronger threats than FCT. While the spread of the technique among other disciplines does show some developing unwillingness to accept unquestioningly psychological direction it is still the case that therapists supporting the method are a minority, therapy professional associations are uncommitted, and many centres that previously supported the method are prepared to accept that its use has been rendered unsafe by the strength of the opposition. In any dispute between psychology and other areas of disability studies psychology has considerable advantages. It can claim to be more scientific, it is certainly more academic, it is unquestionably more influential. Whatever the outcome of the dispute, the opposition of the psychological profession has unquestionably been successful in restricting discussion of facilitated communication training to the area of autism and excluding it from the mainstream of intellectual disability care. The debate over whether ëintellectual disabilityí represents cognitive insufficiency or cognitive defect has been evaded again.
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