Without Autonomy, It’s Not Therapy

Back in the 1980s, in my first full-time job after college, I worked as a house parent and trainer with intellectually disabled adults. I loved the work and the people I worked with. (I’ve always loved working with outsiders, people on the margins of society; probably, in retrospect, because I’m autistic).

 

One incident that stuck in my mind (though there were many similar ones) happened when I was working in the garden with some of the clients and a more senior colleague. My colleague was someone who I admired as a role model, because she showed genuine respect for the people we worked with, treating them as equals and truly wanting the best for them. One of the young men working with us in the garden that day (I’ll call him Pat) had a very gentle nature, too gentle sometimes, and we used to encourage him to stand up for himself more, so as not to get taken advantage of.

That day, two of the senior managers came to visit and look around the location where we were working. They stopped to chat, and some of the clients stopped working and came over to say hello. Pat kept on working on whatever he was doing, and the manager said something like “Come on over, Pat, and say hello”. Pat replied along the lines of “No, I just need to finish what I’m doing here”.

There was a weird moment where my colleague and I jointly had a completely opposite reaction to the one that the managers had. We were delighted – Pat was doing his own thing, instead of just following everyone else; he was being assertive (in his own gentle manner) and deciding what was priority for him at that moment; he was literally standing his ground! To our horror, though, the senior pairing saw him as rude, noncompliant, disrespectful, and they gave out to him, which upset him greatly (we had a lot of reassuring and putting back together to do afterwards).

 

The reason I am telling this story is to illustrate the thinking behind much of what passed for “help”, “therapy” and “care programmes” in those days, and still does nowadays:

Compliance as the goal of “helping” and “therapy” and “training”,

as the criterion of success and progress.

 

When I worked in the field of intellectual disability I wasn’t working as a psychologist or as any kind of therapist, but I was very aware that “Behaviour Modification” was the magical psychological buzz-phrase that was presumed to guide and inform the programmes we were providing - it was held up as the “gold standard manualised evidence-based approach” of those days.

I currently work as a counsellor in private practice, mainly with autistic adults. I don’t work with children, and never have. I therefore don’t have direct professional knowledge of approaches such as Applied Behavioural Analysis (ABA), the most well-known and influential of today’s versions of Behaviour Modification, especially in relation to supposed “therapy” for autistic children.

But the title of this blog post, and the story I’ve just related, should make it clear how I see such approaches:

To the extent that their goals consist in making people’s behaviour

more compliant to institutional needs, they are not therapy.

In fact they are the opposite - they are developmentally damaging.

 

Autonomy is a core human need, and a core developmental need. All human beings, including children, should be free to, encouraged to, educated to:

·       Express disagreement

·       Express discomfort at someone else’s behaviour

·       Question authority figures

·       Ask for explanations for rules or requirements

·       etc

 

Any so-called “therapy” (or supposedly necessary form of “care” or “training”) is in fact counter-therapeutic if it does not provide autonomy in relation to:

·       The choice to participate in therapy

·       The choice to continue or stop therapy

·       Choice regarding the goals of therapy

·       Participation (or not) in any particular therapeutic approaches or techniques

·       The opportunity to give honest feedback about their experience of therapy

 

Conversion “therapy”, for instance, shows its true nature by its lack of adherence to (or interest in) these criteria.

 

I don’t see behavioural methods or behaviourism as the problem as such. A client’s behaviour is just one of the many intertwined aspects of their life that therapist and client might work on together – others are environment, emotions, thinking patterns, physiological awareness, strengths, values/hopes/goals, significant history, family & other relationships, etc.

But compliance-focused “therapies” tend to primarily be concerned with changing behaviour. Emotions, values, beliefs etc only get lip service, because the desired compliance by definition consists entirely of desired changes in behaviour. The problem, of course, is that the changes are not necessarily the ones desired by the person who is getting “therapy”. I certainly know that this is a major concern in relation to the use of ABA with autistic children - they may want help in changing behaviour, but not necessarily the behaviours which are being targeted, or they may want help far more with managing difficult emotions, dealing with relationships, achieving goals, etc.

 

When a person is clear as to specific changes they want to make in their life, behavioural theories and approaches (amongst others) may well be helpful sometimes. For instance, when we are trying to carry out a New Year resolution such as eating more healthily or not losing our temper, then applying a system of rewards for improved habits can be one thing that may help. So we are actually applying a form of behavioural conditioning to ourselves (after all, our susceptibility to conditioning is what formed the bad habits in the first place).

But in this situation it is our choice to take this approach with ourselves

(or with the help of a therapist).

Our autonomy is not threatened, we are following our own desire and decision,

and we can change our minds at any point (we often do!)

 

In the kind of CBT (Cognitive-Behavioural Therapy) that I include as part of my practice, behavioural methods (for instance Graded Exposure or Behavioural Experiments) are not even always primarily targeted at behavioural change. Just as often, therapist and client are using such methods to try and collaboratively achieve helpful emotional and cognitive shifts.

Of course, there are many ways of working that come under the fairly broad heading of “CBT”, some more individualised, empathic and flexible, some less so, but that’s for a future blog post (perhaps the next one…)

 

The reality is that all helping professions (Counselling/Psychotherapy, Psychiatry etc) are institutionalised to some extent, and helping professionals themselves are just human beings. Both human beings and institutions come with strengths & weaknesses, conflicting commitments & agendas, and compromises/trade-offs of time, energy & other resources.

So while my own field of Adult Counselling/Psychotherapy should of course have respect for client autonomy as its highest value (and it certainly does so in principle), that doesn’t mean it always does so in practice. And from what I hear, I think we can safely assume that the same applies across the Mental Health field in general, including Psychiatric services. The worst thing about this situation is that adult clients and patients who are in need of a Counsellor or a Psychiatrist are by definition a very vulnerable population. And people who are vulnerable and in need can often be very compliant with regard to the professional who are helping them. So professionals need to bend over backwards to try and counteract this – complacency is our enemy in this regard. It is not enough to feel that we are not consciously, deliberately educating our clients/patients/service users to be more compliant – we need to make sure that we are actively supporting them to be more autonomous.