Can There be Compassion Without Assent? A Nonlinear Constructional Approach.

 

Abdel-Jalil, A., Linnehan, A. M., Yeich, R., Hetzel, K., Amey, J., & Klick, S. (2023). Can there be compassion without assent? A nonlinear constructional approach. Behavior Analysis in Practice, 1-12. https://doi.org/10.1007/s40617-023-00850-9

Reviewed by Angela Fuhrmann-Knowles, MA, BCBA
Endicott College and Association for Science in Autism Treatment

Introduction

Within applied behavior analysis (ABA), there has been a renewed interest in compassion and assent and providing behavioral services that embody these terms (Breaux & Smith, 2023; Linnehan et al., 2023; Morris et al., 2021; Morris et al., 2024; Taylor et al., 2019). In a recent article, Abdel-Jalil et al. (2023) define these terms, discuss their roles and relevance when employing behavioral services, and provide case examples illustrating how they can be included in practice. In doing so, they provide clarity and guidance for practitioners who may be interested in incorporating compassion and assent within services.

Abdel-Jalil et al. (2023) note the importance of defining compassion and assent in behavioral terms. Taylor et al. (2019) defined compassion as acting to relieve the suffering of another and compared it to empathy, which is recognizing when another is suffering and expressing concern. However, if acting to relieve one’s suffering is controlled or influenced by other variables (e.g., job requirements, receiving payment, success), then one’s actions may not be considered compassionate. For example, Abdel-Jalil et al. explain that a surgeon can provide relief to a patient by performing life-saving surgery, but if the surgeon fails to learn the patient’s name nor follows up with them after the surgery, it is unlikely that we would call them compassionate. As noted by the authors, the doctor’s ability to perform life-saving surgery competently and successfully is likely what maintains their behavior rather than acting compassionately. In the eyes of the doctor, if they can perform the surgery successfully, learning their patient’s name may not be as important. Although one might argue that an inconsiderate expert surgeon may be more desirable than a compassionate surgeon with less expertise, the authors pose the question: Why not have a surgeon with expertise and compassion? This example draws parallels to families, caregivers, or clients who may have encountered practitioners who were experts but lacked compassion or interpersonal relationship skills. As such, the same question can be asked regarding ABA services: Why not have practitioners with expertise and compassion?

The Role of Assent and Compassion

Consent and compulsion (i.e., coercion) are also relevant terms in practice (Linnehan et al., 2023). Consent is typically considered a distinct event (Linnehan et al., 2023). For example, when one signs a document or vocally says, “I agree,” before participating in a research study or undergoing surgery, they are providing consent. In contrast, assent involves continuous assessment of one’s participation. Abdel-Jalil et al. (2023) state that compassionate practices are those in which a practitioner continuously obtains and assesses a learner’s assent. Another important difference between consent and assent is that consent can only be obtained from an individual who can legally make an agreement, whereas assent can be obtained from any organism, regardless of legal ability. This point highlights that assent can be obtained when working with learners who do or do not have vocal language, are of any age, or are non-humans (e.g., animals).

Compulsion can occur with any organism and involves applying an aversive consequence when a learner stops participating or refuses to participate in a program, activity, or event (Linnehan et al., 2023). For example, if a learner completes their chore (e.g., washing the dishes) because otherwise, they would have to complete an additional chore (e.g., vacuuming), this would indicate compulsion. One might assume that the learner in this scenario is willing to participate in completing their chore; however, if they do not complete it, they have to complete an additional chore, which they find aversive. Rather than stating that the learner is willing to do their chore, it is more accurate to say they are compelled to do it. It should be noted that practices like these may be common in ABA-based programs or everyday parenting practices to increase or decrease behaviors. The purpose of this paper is not to criticize these practices but to highlight that, for those who are hoping to move towards incorporating assent into practice more meaningfully, careful analysis of the different arrangements that have been set up for learners is required before we can say assent is present. In essence, obtaining or assessing one’s assent is more than simply identifying if a learner appears willing to participate. Responses such as smiling, answering questions quickly, and approaching the work area might indicate a willingness to participate and that one is assenting to participate in a program, but more information is needed. As highlighted by Abdel-Jalil et al. (2023), there are various situations, such as the scenario illustrated above, in which we might become willing to do something due to the threat of a particular consequence for not doing it. As such, to be considered assent-based or compassionate, these variables must be considered.

Abdel-Jalil et al. (2023) also described two types of assent: genuine and apparent (see Linnehan et al., 2023). Genuine assent means a learner has more than one way to earn a reinforcer. For example, if a learner can earn their iPad by washing the dishes (option 1) or vacuuming (option 2), then genuine assent can be established. When a learner stops participating or has never previously participated in a specific program, this should prompt a behavior analyst to first assess the program instead of restricting access to a reinforcer to increase participation or ending the program completely. For instance, if the learner is constantly choosing to wash the dishes, but vacuuming is also an important skill to learn, then variables should be identified as to why washing dishes is preferable to vacuuming. The learner may not know how to vacuum, or the loud noise from the vacuum may be aversive. If the learner is taught the skills to vacuum or is given headphones to listen to music while vacuuming to decrease the aversiveness of the noise, one might observe an increase in the learner’s participation in completing the task. Apparent assent occurs when a learner only has one way to earn a reinforcer. For example, when a learner can only access their iPad by washing the dishes this is considered apparent assent. As such, apparent assent is also considered a form of compulsion (for a further analysis of these terms, the readers are encouraged to read Linnehan et al., 2023).

Due to the common use of these methods to increase participation in programs, some may resist considering that some level of compulsion exists within them. For instance, current best practices for toilet training indicate that higher preferred items should be reserved for when a learner successfully voids in the toilet (Greer et al., 2012; Perez et al., 2020). As such, for those interested in incorporating genuine assent in programs like toilet training, more research is needed to identify how to do so while producing effective outcomes. Another common area in which reinforcers are reserved for engaging in a goal behavior is when addressing food selectivity (Peterson & Ibañez; Volkert & Piazza, 2012). Recent research has detailed how assent can potentially be incorporated into interventions which address food selectivity (Gover et al., 2023). In Gover et al. (2023), the participants’ highest preferred items were reserved for engaging in food consumption, but assent was incorporated into the intervention by continually assessing each learner’s participation and allowing them to leave and return to the treatment area at any time. The results indicated that food consumption increased across each participant and the results maintained when implemented by the caregivers. Additional research should be conducted to identify ways in which genuine assent can be incorporated into these types of programs.

Importantly, the intent of the paper by Abdel-Jalil et al. (2023) is not to criticize but to help behavior analysts think more critically about what it means to incorporate assent into practices, and they provide examples of how to do so. Particularly, Abdel-Jalil et al. discuss how the Constructional Approach (Goldiamond, 1974/2002) and nonlinear contingency analysis (NCA; Layng et al., 2022) can be utilized as effective behavior-change methods that also incorporate genuine assent from learners. Notably, the authors discuss how discontinuing a program in response to a learner’s assent withdrawal is not always ideal because teaching new skills is a main priority. However, restricting a reinforcer to increase participation is not ideal either. Rather, the authors describe the ideal teaching situation as one in which learning occurs while assent is continuously monitored and adjustments to a program are made in response to a learner’s assent withdrawal.

Before Beginning, Ask: Is the Program Necessary?

Because the process of gaining assent can take considerable time and effort, Abdel-Jalil et al. (2023) suggest that practitioners assess whether the program is beneficial to the learner before using considerable time and effort. If the learner is not likely to benefit from the program that occasions assent withdrawal, then it may be more useful to remove the program. However, if the learner is likely to benefit and achieve socially significant outcomes from the program, it may be worth the effort.

The authors present two examples, the second of which will be discussed here. Abdel-Jalil et al. (2023) describe a 10-year-old learner in a classroom setting who is working on a reading program. The teacher asks them to read, but the learner refuses and places their head on the table. Before putting forth the effort to obtain assent, one should ask the following:

• • What are the outcomes of this program, and are they worth the time and effort to gain assent for participation?
  • How does this program benefit the learner’s overall growth and development?

As a result of this program, the learner’s reading will improve, which creates many opportunities for the learner, such as inclusion in groups, joining reading activities, engaging and interacting with different materials and objects of interest, and reading directions to play games. As such, the learner’s participation in the reading program is likely to benefit their overall growth and development, indicating that time and effort should be spent to increase their participation in the program (i.e., obtain their assent). If a program is beneficial yet assent is withdrawn, Abdel-Jalil et al. suggest turning to the guiding questions outlined in the Constructional Approach to assist in program development.

The Constructional Approach

The Constructional Approach, first outlined by Goldiamond (1974/2002), focuses on building repertoires rather than eliminating them. Within this approach, there are five guiding questions (see table below). The first question asks, “Where does one want to go?” This question helps to identify the goals and outcomes one desires to achieve. Whenever possible, it is suggested that learners and recipients of services or treatment be involved in the goal-selection process.

The second question asks, “Where are they now?” In other words, “What skills can this learner already do?” These entry skills can be built upon and shaped into the goal behaviors or desired outcomes. For example, a learner may have the desired outcome of making friends at school. Some skills this learner has before an intervention begins might include the ability to play different games, such as board games or outdoor games, and vocal language skills. Playing board games with adults could be shaped into playing with a similar-aged peer, and their vocal language could be shaped into conversational skills.

The third question asks, “What can one do to get them there?” In other words, “How can we help them achieve their desired outcomes?” This question helps one develop the program or interventions that will be used to help their learner achieve their desired outcomes. The fourth question asks, “What will keep them going?” or “What will maintain one’s participation in the program?” Some examples of maintaining consequences for the learner who wants to make friends at school might be the reinforcement received when conversing or playing with peers, support from caregivers or teachers, learning new information when discussing different topics with peers, or learning to play new games. The fifth question asks, “How does one follow progress?” This question helps outline how data will be collected on a learner’s performance throughout the program. For a further explanation of the Constructional Approach, see Goldiamond (1974/2002) and Layng et al. (2022).

 

Guiding Questions Where does one want to go? Where are they now? What skills do they currently have? What can we do to help them to their desired outcomes? What will keep them going? What will maintain their participation in the program? How does one follow their progress?

 

Abdel-Jalil et al. (2023) state that using these questions to guide program development will help clinicians incorporate assent into practice. The following section illustrates several case examples in which the Constructional Approach was used to monitor, obtain, and program for assent in practice. Two of those case examples will be described here.

Case Example with David: Providing Component Repertoires

One case described by Abdel-Jalil et al. (2023) is that of a 9-year-old boy named David. David had social skills but struggled with academic skills. He was observed to successfully answer questions vocally that were presented to him by the teacher during a math lesson. After this lesson, the students were given a worksheet to complete a writing task. The teacher noticed that the fours David wrote were incorrect and asked him to rewrite them. David wrote another four, but the teacher erased it and told him to try again. He yelled at her, saying they were correct. Then, he crumbled up his paper and left the classroom.

The authors note that, in this example, David willingly participated when the teacher required vocal responses during the lesson, but David no longer assented to the program once it changed to writing. The guiding questions and corresponding answers were as follows:

1. 1. Desired outcome: David would sit with his peers and complete all his work (both vocal and written assignments).
   2. David’s current skills: He completes work that requires vocal responses, can scribble when coloring, can make horizontal and vertical straight marks, and tries to write letters and numbers.
   3. Plan of action: While David’s peers complete the usual writing lesson, an assistant teacher will implement a handwriting program with David to build his writing skills. Assent was continuously monitored. David could walk out of the classroom at any time (one degree of freedom). If David walked out of the classroom, this did not mean that math was no longer taught, but rather, it indicated to the teacher that the program needed to be adjusted to increase David’s participation (i.e., assent).

This case presented by Abdel-Jalil et al. (2023) highlights the importance of identifying one’s current skills and using those to build upon and develop new skills. David ultimately reached the desired outcome of completing all his work, both vocal and written assignments. This case example demonstrates how one could incorporate genuine assent and compassionate practices into programs.

Professional Practice with Animals: Lessons to Be Learned

It is sometimes assumed that nonverbal individuals cannot provide genuine assent. The following sections in this paper detail case examples with animals (i.e., nonverbal organisms) and how their trainers obtained and incorporated genuine assent into their programs. Although many professionals and practitioners in applied behavior analysis (ABA) work with autistic learners rather than animals (Behavior Analyst Certification Board, 2024), these case examples demonstrate that it is possible to incorporate genuine assent into programs with many, if not all, types of learners (e.g., humans, non-human animals).

Because animal trainers are often under tight deadlines and have to perform high-risk procedures, this can lead to using interventions that prioritize urgency and expediency rather than compassion and assent. Abdel-Jalil et al. (2023) note that during medical procedures, animals may be restrained, with the rationale that it only takes a few seconds, they will not remember it, and it only occurs once a year. This reasoning can create conflict for those who want to engage in more assent-based and compassionate practices.

The Whole Life Training Plan (Alm et al., 2009; Clifton-Bumpass, 2022), based on NCA and the Constructional Approach, can be used by animal trainers to provide services based on assent and compassion. The Whole Life Training Plan was first taught in 2006 by Lisa Clifton-Bumpass to the team responsible for the giraffes at the Oakland Zoo. This training plan emphasizes building skills for an animal that will help them navigate a multitude of situations. Some situations include separating from their herd, media events, meeting new people, blood draws, injections, and hoof care. This plan is used to identify an animal’s current skills and builds upon them. Trainers can use the animal’s current skills to measure assent during training interactions. Two case examples with animals are presented in this paper; however, only one (Case Example 4) will be described here.

Case Example with Sharkbite the Sea Lion: Willing Participation in Medical Care

Case Example 4 details the case of a California sea lion named Sharkbite, who was named after surviving multiple shark attacks. Sharkbite had permanent eye damage as a result. Sharkbite needed training to receive voluntary injections, a hallmark of high-quality training for animals under human care. When training sea lions to receive injections, these steps are usually followed: (1) the sea lion lays behind a barrier, such as a fence, (2) cleansing wipes are used to clean the injection site, and (3) the injection is given. The barrier protects the trainer from aggression from the sea lion. These steps were used to train Sharkbite to receive injections. The only way Sharkbite could earn his reinforcer (fish) was to receive the injection, indicating zero degrees of freedom. Previous trainers were unsuccessful in working with Sharkbite. His new trainer observed that Sharkbite did not have many positive interactions with humans and started his program by teaching him skills that would help him succeed in human care.

The first skill taught to Sharkbite was “targeting.” Sea lions are curious animals and investigate unfamiliar items with their nose. This behavior can be shaped by a trainer to teach the sea lion to touch their fist or a target stick when given the cue/instruction, “Target.” After the targeting skill has been taught, it can be used to measure the sea lion’s assent during a training interaction. For example, the trainer can assess the magnitude or force of the response (e.g., touching the target vs. pushing/forcing it away or not touching it at all). If pushing an unfamiliar item away, targeting with force, or not targeting at all, these responses could indicate to the trainer that the sea lion is withdrawing their assent.

Teaching a sea lion to target gives them an alternative behavior in which to engage. Additionally, if the sea lion targets and still accesses the fish, this arrangement provides another degree of freedom. The following arrangement is detailed below:

• • Cue/signal from trainer to engage in behavior (“Target”) → sea lion engages in cued behavior → receives fish
  • Cue/signal from trainer to engage in behavior (“Target”) → sea lion engages in forceful target or does not target → receives fish

Additionally, Sharkbite’s enclosure remained open so he could leave the training session anytime. In Sharkbite’s program, he always had at least two degrees of freedom:

1. 1. Participates in the program → receives fish
   2. Forceful target or does not target → receives fish
   3. Walks back to his enclosure → receives fish

The next skill taught to Sharkbite was to allow the trainer to touch his body while remaining in the same position (lying on his stomach). The trainer then taught Sharkbite to acclimate to tactile sensations, including taps, pokes, and brushes. Helping Sharkbite acclimate to these sensations extended beyond receiving voluntary injections and allowed him to thrive under human care in various future situations. As a result of this program, Sharkbite assented to his injections with a novel trainer. Sharkbite was restrained during injections previously, but he learned new skills through a program based on NCA and the Constructional Approach, which was ultimately a more compassionate and effective approach for him.

Conclusion

Many different researchers have emphasized the integration of values-based approaches into ABA intervention; these include assent, compassion, cultural responsiveness, and trauma informed care. Through this current article, Abdel-Jalil et al. (2023) illustrate how genuine assent can be incorporated into behavioral programs with humans and non-human animals. The authors close their article by noting that compassionate care and genuine assent go hand in hand in that one must incorporate genuine assent into programs if those programs are to be considered compassionate. Incorporating assent into programs does not mean that learners make every decision or that skills are not taught if they do not want to learn them. The purpose of behavioral services is always to create socially significant and meaningful outcomes for learners, their caregivers, and other stakeholders. We have an ethical obligation to do so. Incorporating assent allows a behavior analyst to carefully examine the programs they are developing. If a learner is not participating, how can the program be adjusted? Is the program worth it? Can it be made more enticing and engaging? What changes can be made to increase the learner’s participation without restricting a reinforcer? How can learner choice and preference be maximally integrated into the program? How can indicators of assent and dissent be individually assessed and then honored in intervention? What skills does the learner have now that can be used to build other skills? By using these questions to guide program development, behavior analysts can implement programs that prioritize genuine assent and compassion.

References

Alm, V., Dougall, A., Clifton-Bumpass, L., Goodnight, A., Phelps, A., & Holub, S. (2009). The future is now: Geriatric animal husbandry and training. The International Zoo News, 56(3).

Behavior Analyst Certification Board. (2024). BACB certificant data. https://www.bacb.com/bacb-certificant-data/

Breaux, C. A., & Smith, K. (2023). Assent in applied behaviour analysis and positive behaviour support: Ethical considerations and practical recommendations. International Journal of Developmental Disabilities, 69(1), 111-121. https://doi.org/10.1080/20473869.2022.2144969

Clifton-Bumpass, L. (2022). Constructional team building: What we can learn from four institutions over 14 years and hundreds of human and animal competency assessments [Symposium presentation]. 48th Annual Conference of the Association for Behavior Analysis International, Boston, MA.

Goldiamond, I. (2002). Toward a constructional approach to social problems: Ethical and constitutional issues raised by Applied Behavior Analysis. Behavior and Social Issues, 11(2), 108-197. https://doi.org/10.5210/bsi.v11i2.92 (Original work published in 1974).

Gover, H. C., Hanley, G. P., Ruppel, K. W., Landa, R. K., & Marcus, J. (2023). Prioritizing choice and assent in the assessment and treatment of food selectivity. International Journal of Developmental Disabilities, 69(1), 53-65. https://doi.org/10.1080/20473869.2022.2123196

Greer, B. D., Neidert, P. L., & Dozier, C. L. (2015). A component analysis of toilet‐training procedures recommended for young children. Journal of Applied Behavior Analysis, 49(1), 69-84. https://doi.org/10.1002/jaba.275

Layng, T. J., Andronis, P. T., Codd III, R. T., & Abdel-Jalil, A. (2022). Nonlinear contingency analysis: Going beyond cognition and behavior in clinical practice. Routledge.

Linnehan, A. M., Abdel-Jalil, A., Klick, S., Amey, J., Yeich, R., & Hetzel, K. (2023). Foundations of preemptive compassion: A behavioral concept analysis of compulsion, consent, and assent. Behavior Analysis in Practice. https://doi.org/10.1007/s40617-023-00890-1

Morris, C., Detrick, J. J., & Peterson, S. M. (2021). Participant assent in behavior analytic research: Considerations for participants with autism and developmental disabilities. Journal of Applied Behavior Analysis, 54(4), 1300-1316. https://doi.org/10.1002/jaba.859

Morris, C., Oliveira, J. P., Perrin, J., Federico, C. A., & Martasian, P. J. (2024). Toward a further understanding of assent. Journal of Applied Behavior Analysis, 57(2), 304-318. https://doi.org/10.1002/jaba.1063

Perez, B. C., Bacotti, J. K., Peters, K. P., & Vollmer, T. R. (2020). An extension of commonly used toilet‐training procedures to children with autism spectrum disorder. Journal of Applied Behavior Analysis, 53(4), 2360-2375. https://doi.org/10.1002/jaba.727

Peterson, K., & Ibañez, V. (2018). Food selectivity and autism spectrum disorder: Guidelines for assessment and treatment. TEACHING Exceptional Children, 50(6), 322-332. https://doi.org/10.1177/0040059918763562

Taylor, B. A., LeBlanc, L. A., & Nosik, M. R. (2018). Compassionate care in behavior analytic treatment: Can outcomes be enhanced by attending to relationships with caregivers? Behavior Analysis in Practice, 12(3), 654-666. https://doi.org/10.1007/s40617-018-00289-3

Reference for this article:

Fuhrmann-Knowles, A. (2025). Article Review: Can there be compassion without assent? A nonlinear constructional approach. Science in Autism Treatment, 22(2).

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