REPLY TO S. DRAKE - ROUND AND ROUND ON AVERSIVES
Tom=Linsche...@aloha.chi.ohio-state.edu
Let me expalin before I get started here that my mail program doesn't allow
me to include text from prior messages if those are received as attachments
and all of my posts from the Autism list come as attachments. I just don't
have the time to retype all the text to which I am responding. I know this
makes it difficult sometimes for those who haven't seem earlir posts so I
will try to at least write in a way that suggests the content of the original
text.
*****
As to the issue of 5000 shocks in one day and my unwillingness to comment on
that and whether "behavioral theory" supports that. Again, behavior analysis
as a science is involved with the demonstrations of functional relationships
between behavior and environment. Knowledge of behavioral principles can be
"applied " in many forms without changing the theory. Electricity is
electricy regardless of how it is used. The relationships between resitence,
current flow and voltage are not changed by whether they are applied for
good or evil. So again, the question of 5000 shocks in one day is a question
of application not of theory.
If the question is, can 5000 shocks a day ever be justified as an
application, let us look at a couple of senarios. The first hyothetical
situation; the baseline rate of a severe self-injurious behavior is 20,000
per day, when we begin to treat the behavior with contingent electric shock,
the rate is 4000 the first hour, then 1000 the second hour and then the
behavior does not occur for the remaining 22 hours of that day. I can see
where this may be considered acceptable by many, especially if the behavior
continues at a very low or zero rate over subsequent days and weeks.
Senario number two. The baseline rate is 5000 per day and once treatment
starts there is no change over the course of the entire day and therefore the
person receives 5000 shocks. In this situation, continuation of the
treatment is not justified because it is not effective.
My point in not commenting on the newspaper article is that I did not know
the circumstances of the treatment case, especially as to baseline rates and
rate of behavior accross the day. Without this information it would be hard
to answer the question of whether the reported number of shocks was
justified. If I were the parent of the person described in the first
scenario, I would be happy and relieved that my child was no longer engaging
in SIB 20,000 times a day, as the parent of the person in the second
scenario, I would be dismayed that the treatment didn't work and that my
child had to receive 5000 shocks.
The point is, without the knowledge of baseline rates and rates of behavior
during the treatment day, it is not possible, from my point of view, to
either support or not support the application of 5000 shocks in one day. If
you are opposed to contingent electric shock as a treatment then knowledge of
its effectivenss is irrelevant and you will be opposed regardless of details.
I do certainly agree that when numerous aversive stimuli are administered in
one day, the therapists are accountable for justifying the practice but I do
not agree that it is automatically a bad practice - it depends on many
factors, not just the number. I hope the above scenarios help to point out
why I think such decisions are best left to parents, clinicians and oversight
committees and why it is difficult to have a blanket statement about things
such as maximum numbers of shocks etc... The reason we do not rule out
chemotherapy (very aversive to those who receive it) is that we consider it
in context (effectiveness, alternatives, result of not treating etc) - I
think this holds true in behavioral applications as well.
********
As to my question to you regarding what behaviors would convince you that a
person wanted SIBIS, you indicated that there probably are no behaviors that
would convince you. Therefore, I am assumming that you have made your mind
up on that point and there is no further need for discussion. I just find it
hard to understand how some people can believe that a person wants juice
after they point to a picture of juice and willingly drink it but that same
person couldn't really want SIBIS even though they point to a picture of it
and then willingly help put it on after it is brought to them. Seems
inconsistent but that is your belief system I guess.
*******
As to the whole issue of the Berkman and Meyer article. It should be
remembered that their "findings" were being cited frequently in support of a
strictly non-aversive agenda and done in a way to suggest that there was only
one interpretation of their data. Judy Badner seems to agree with us that
medication could have been helpful and a significant aspect of the reported
treatment. And while Berkman and Meyer briefly refer to a failed drug
holiday their description does not include data on his behavior during that
time (which they had) and it reads as though the drug holiday failed because
staff could tell that a placebo was used. As a psychiatrist, I think she
knows that Thorazine, the medication in question, was originally developed as
an antiemetic (vomiting was one of the major problems in the man described in
the article). She probably also knows that the doses he was receiving were
well above those recommended in the PDR (the highest was 1400 mg per day).
It is also true the this man had thorazine before but it had been given in
crisis (sometimes IM) situations for only a few days at most and had never
been systematically used and evaluated over longer periods with gradual
increases as described during the course of the simultaneous non-avesive
programming and drug treatment.
Landau and I feel we are justified in pointing out that medication probably
played a significant role in the man's improved behavior and life. We did
not say that the non-aversive program was not a factor, we just did not agree
with Berkman and Meyer that their article should be interpreted as indicating
that an aversive was not needed in the case in which the article was
submitted as evidence. We really don't think that the Berkman and Meyer
article can provide any conclusions regarding that issue. Unfortuantely, it
was being used for that purpose and subsequent to our re-examination article
I have seen it used less and less.
Our point was that, as "research" on the effectiveness of a positive only
approach, it was very weak given the confounding with an ongoing medication
trial. We do not believe that it is strong evidence for never using
aversives and Meyer and Berkman seem to agree when they say "We leave it to
the readers to decide whether self-determination, a decent lifestyle,
Thorazine or being reunited with his father resulted in the changes we
reported in Mr. Jordan's situation."(Meyer and Berkman, Mental Retardation,
1993,31, pp 7-14). It seems from this quote that they agree there is room
for several interpretations, that is all we were pointing out. We just
wanted the readers to have accurate information about the medication used
during the non-aversive program so that they could make a more informed
decision. Berkman and Meyer had reported it as a constant dose throughout
treatment, that was not accurate.
Tom=Linsche...@aloha.chi.ohio-state.edu
>We seem to be arguing about different interpretations of the same
>article. From my reading of the article, it was very clear that the
>behavior became worse when the person was taken off Thorazine. I did
>not see any attempt to minimize or hide that fact.
If you read the discussion section you will find a quote to the effect that
the authors don't believe that anything else can explain the good outcome
except their positive only program.... i found it interesting that they
presented the data during all phases of their intervention except the drup
trial - that data would have made it very clear that the medication was
playing a substantial role in change in Mr. Jordan's behaviors.
linscheid says
>Landau and I feel we are justified in pointing out that medication probably
>played a significant role in the man's improved behavior and life. We did
>not say that the non-aversive program was not a factor, we just did not agree
>with Berkman and Meyer that their article should be interpreted as indicating
>that an aversive was not needed in the case in which the article was
>submitted as evidence. We really don't think that the Berkman and Meyer
>article can provide any conclusions regarding that issue. Unfortuantely, it
>was being used for that purpose and subsequent to our re-examination article
>I have seen it used less and less.
Jbadner says
>Well, personally, I don't think any case report can be used to
>demonstrate the efficacy of any treatment. But, I fail to see how
>even if the improvement was due primarily to Thorazine, how that fails
>to indicate that an aversive was not needed. If someone's suicidal
>behavior remits with an antidepressant, does that fail to indicate
>that an aversive was not needed?
The point of this whole discussion about this article was that it was being
touted as proof that an aversive was not needed based on the documented (?)
success of the non-aversive program. It wasn't being acknowledged that
medication may have played an equal or even greater role (see the discussion
section). That was the purpose for our article, to point this out - even
though the authors briefly describe the failed drug holiday, they concluded
that the behavior change was due to their program, not the medication, that
is the problem with their conclusion. We agree with you that this is a case
report in which no conclusions can be drawn about cause and effect - but the
authors did draw conclusions and therefore we seem to be in agreement.
tom