Review of Interrogating neurotypical bias in Facilitated Communication, Rapid Prompting Method, and Spelling 2 Communicate through a humanistic lens

Schlosser, R. W., & Prabhu, A. (2024). Interrogating neurotypical bias in Facilitated Communication, Rapid Prompting Method, and Spelling 2 Communicate through a humanistic lens. Current Developmental Disorders Reports, 11(1), 41-51. https://doi.org/10.1007/s40474-024-00296-w

Reviewed by
Angela Fuhrmann-Knowles, MA, BCBA
Endicott College

A review of Interrogating neurotypical bias in Facilitated Communication

Credit: Artwork by Marina Azimova, EdM, MSW, BCBA

Reports have indicated that approximately 25-35% of autistic individuals have minimal to no speech and often require support in communicating (Rose et al., 2016). Augmentative and alternative communication (AAC) is an evidence-based practice that has provided an outlet for individuals with minimal to no speech to communicate effectively. AAC systems may consist of manual signs, non-electronic communication boards, speech-generating devices, or AAC-specific applications on tablets (Beukelman & Light, 2020; Bowman, 2023; Courtney, 2013). Despite the recognition of AAC as an evidence-based practice and its effectiveness as a communication modality, those who support autistic individuals (e.g., caregivers, family members, therapists) may rely on facilitator-dependent methods such as Facilitated Communication (FC), Rapid Prompting Method (RPM), and Spelling 2 Communicate (S2C), which have little to no empirical support. Schlosser and Prabhu (2024) highlighted the concerns around the use of these methods and how their use may violate an autistic individual’s human rights.

Schlosser and Prabhu (2024) note that many proponents of FC, RPM, and S2C incorrectly classify them as AAC systems. One notable difference between these methods and AAC is that AAC allows for the independent production of communication and providers are systematically working toward that outcome, whereas FC, RPM, and S2C are considered facilitator-dependent methods. A communication modality is considered “facilitator-dependent” when it requires the physical support of a facilitator in order for an individual to communicate. For example, FC could involve an individual pointing to letters on a keyboard while the facilitator provides physical support by moving the individual’s hand to type different letters and words. Similarly, with RPM, this usually involves a facilitator holding a letter board while using various prompts to bring about responses from the individual in the form of selecting different letters. It is important to note that, as a behavior analyst who implements behavior-change programs with autistic individuals, prompting or physical support may be utilized when teaching an individual communication skills, such as how to use AAC (Biggs et al., 2018; Finke et al., 2017; Tereshko, 2022). However, the physical support is removed to allow individuals to communicate independently. In contrast, support is not removed with facilitator-dependent methods.

Many concerns exist regarding the use of these methods as will be outlined in the remainder of this review; however, they are being overshadowed by a number of factors. Lilienfield et al. (2014) outlined the ways in which FC continues to persist, including (1) continued use as an intervention, (2) continued endorsement from academic and institutional settings, (3) growing popularity online and in print, (4) promotion in the media as a method for releasing unheard voices, and (5) cases in which caregivers are accused of sexual abuse. Further, documentaries portraying success stories of individuals using S2C and FC have garnered support for their use. Despite the lack of evidence for FC, RPM, and S2C, the popularity of these methods continues to grow (Chouinard, 2024; Jardine, 2024; Peters, 2023; Skenazy, 2022).

The use of FC and its variants is approached by Schlosser and Prabhu (2024) through a humanistic lens. Schlosser and Prabhu state that it is likely a humanistic, rather than a scientific, impulse that is driving the use of these methods. The humanistic impulse being to validate and access the thoughts and desires of non-speaking autistic people. Unfortunately, evidence has shown that the messages generated by non-speaking autistic individuals using these methods have been generated by facilitators (Boynton, 2012; Felce, 1994; Hemsley et al., 2018; Wheeler et al., 1993). In using facilitator-dependent methods, facilitators are likely hindering the voice of non-speaking individuals by speaking for them and assigning them a voice that is not theirs. Additionally, because non-speaking individuals are conversing in a non-normative language (i.e., AAC), the power dynamic favors the normative speaker. As such, Schlosser and Prabhu highlight the power imbalances that occur when using facilitator-dependent methods.

Power Imbalances: Insights from Postcolonial Studies

In a presentation to the National Council for Severe Autism (NCSA), Todd (2021) stated that a power differential exists in FC when a neurotypical speaking person (i.e., facilitator) physically manipulates the communication of a non- or minimally speaking autistic individual. Schlosser and Prabhu (2024) compared the power imbalances between non- or minimally speaking individuals and neurotypical individuals in FC to those discussed in postcolonial studies. For example, Chakrabarty (1992) suggested that due to British colonialism, authentic Indian histories have been overwritten through a master (i.e., British, European) narrative. Similarly, the history and experiences of autistic individuals may be overwritten by the master (i.e., neurotypical) narrative, particularly when facilitator-dependent methods are used, and other people speak for them. Schlosser and Prabhu stated that ignoring the evidence that details the harms of FC is a form of epistemic violence in which the needs and desires of autistic individuals are knowingly distorted.

FC (and Potentially RPM/S2C) as a Form of Ventriloquism

Schlosser and Prabhu (2024) discussed how ventriloquism has been used as a metaphor for colonial oppression. Ventriloquism is defined as “the ability to speak without moving your lips so that your voice seems to be coming from someone or something else, usually as a way of entertaining people” (Cambridge Dictionary). Routh (1994) was the first to compare the use of FC as a form of ventriloquism. FC facilitators have even been referred to, by some, as ventriloquists (e.g., Spruce, 2016).

The authors note an important distinction between ventriloquism and FC. For instance, when one is watching a ventriloquist act, they are usually aware that the ventriloquist, rather than the puppet, is talking. The audience typically understands that although the ventriloquist may be highly skilled in their craft, they did not communicate with the puppet. In FC, key stakeholders (e.g., parent, caregiver, friend) often believe that the non-speaking autistic individual is conversing with them. The key stakeholders respond as though the autistic individual is communicating with them. Because the communication partners are unaware that their loved one is not actually communicating with them, it is considered deceptive and oppressive. Boyton (2012) detailed her own experience as a former facilitator in which she advertently and inadvertently authored messages on behalf of the autistic individual, Betsy, whom she worked with and wrote messages she believed they would say, which resulted in false accusations of sexual abuse against Betsy’s family. With ventriloquism, the audience knows it is an act. With FC, the communication partners may believe they are communicating with their loved ones and that the messages are authored by them.

The Evidence Base

When FC was first introduced in the 1990s, it was described as a miracle intervention that gave autistic individuals the ability to communicate in ways they never previously could. However, as investigators began conducting research studies on FC to validate its effectiveness, they discovered major flaws. Wheeler et al. (1993) conducted an experiment in which the facilitators and autistic individuals were sometimes shown the same pictures (e.g., a picture of an apple), and at other times, they were shown different pictures (e.g., the facilitator saw a picture of an apple, the autistic individual saw a picture of a cup). The facilitators and the autistic individuals were unaware of the picture that the other was seeing. The results indicated that whenever the facilitators and autistic individuals were shown the same pictures, they would provide the same responses. When the pictures differed, the spelled output from the autistic individual would describe what the facilitator saw, indicating that the facilitator, rather than the autistic individual, was providing the spelled output. Many additional studies were conducted and found similar results, disproving the initial claims of FC as a miracle intervention. Currently, no well-designed nor well-controlled research studies exist that indicate that autistic individuals are authoring messages when using FC. Due to the lack of evidence, multiple organizations and institutions, including the American Academy of Pediatrics (AAP), the American Speech-Language-Hearing Association (ASHA), the American Association on Intellectual and Developmental Disabilities (AAIDD), and the Association for Science in Autism Treatment (ASAT), the NCSA, and the International Society for Augmentative and Alternative Communication (ISAAC) have developed position statements against the use of FC. Please refer to Celiberti et al. (2024) for links to these position statements.

RPM and S2C also lack empirical support. Because these methods are facilitator-dependent, Schlosser and Prabhu (2024) stated that experiments using RPM and S2C will probably produce similar findings to those in FC experiments. Schlosser and Prabhu suggested that clinicians consider RPM and S2C adjacent to FC and take the same precautions regarding facilitator-controlled messages.

One major concern with RPM and S2C is the use of non-stationary displays. For example, a facilitator can move the letter board and hold it in different places (either advertently or inadvertently), which could influence an autistic individual’s letter selection. In one example, a former FC facilitator observed a facilitator repeatedly call out letters that were not selected by the autistic individual (Boynton, 2012). To date, there is no evidence that verifies autistic individuals are producing messages when using RPM and S2C.

Barriers to Authorship Testing

Many proponents of facilitator-dependent techniques discourage facilitators from authorship testing, which creates a barrier to establishing evidence-based practices. Proponents of these methods and self-advocacy networks want to protect individuals’ right to communicate and claim that RPM/S2C is the only way for some individuals to communicate. Schlosser and Prabhu (2024) expressed the same concern over ensuring that autistic, non-speaking individuals have the means to communicate and, for this reason, asserted that authorship testing should occur. Some claim that RPM/S2C is different than FC; however, the concern remains that these methods are dependent on a facilitator. Todd (2021) stated that the facilitators, rather than the autistic individuals, typically prevent authorship testing. By failing to verify authorship, the production of products, training, and consultations continues, indicating that monetary gains may be a motivating factor in preventing authorship testing. The prioritization of monetary gains over the rights of autistic individuals brings forth ethical concerns. Additionally, in failing to verify authorship, RPM/S2C cannot be considered an evidence-based practice.

Facilitated Communication and Neurodiversity

“Neurodiversity” is a term coined by Judy Singer, which means that everyone experiences the world in different ways and that diversity should be valued (Singer, 2016). The Neurodiversity Movement has advocated for the rights of disabled individuals, including autistic individuals. Schlosser and Prabhu (2024) stated that the messages generated through facilitator-dependent methods (e.g., FC, RPM, S2C) are not authentic autistic voices because they are not produced by the individuals themselves. Instead, they are the voices of the facilitators. As such, these methods do not appear to align with the Neurodiversity Movement. Even so, advocacy groups, such as the Autistic Self Advocacy Network (ASAN), have stated that discouraging the use of FC, RPM, and S2C is impeding autistic individuals’ right to communicate. However, evidence has indicated that facilitators produce the messages when using FC, meaning that using FC and related methods actually impede autistic individuals’ right to communicate.

In Summary

The article by Schlosser and Prabhu (2024) examined facilitator-dependent techniques, such as FC, RPM, and S2C, and drew parallels to postcolonial theory. Schlosser and Prabhu summarized five main points, including (1) the use of FC can result in epistemic violence against autistic individuals because it has the potential to distort their desires, (2) FC operates similarly to ventriloquism, (3) developers and proponents of RPM/S2C must produce research evidence that autistic individuals are authoring the RPM/S2C messages, (4) authorship testing is imperative prior to adopting FC, RPM, or S2C as an autistic individual’s communication modality, and (5) FC, RPM, and S2C do not align with the Neurodiversity Movement.

In addition to these points, real harms resulting from the use of facilitator-dependent techniques have been documented, including sexual abuse (Boynton, 2012; Sherry, 2016). Importantly, the use of FC, RPM, and S2C takes time away from the use of evidence-based practices, such as AAC, which have been proven to give autistic individuals a voice independent of a facilitator. Schlosser and Prabhu (2024) recommend focusing efforts on the use of AAC and, in doing so, truly amplifying the voices of autistic individuals.

References

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Citation for this article:

Fuhrmann-Knowles, A. (2024). A review of Interrogating neurotypical bias in Facilitated Communication, Rapid Prompting Method, and Spelling 2 Communicate through a humanistic lens. Science in Autism Treatment, 21(7).

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Review of Interrogating Neurotypical bias in Facilitated Communication, Rapid Prompting Method, and Spelling 2 Communicate Through a Humanistic Lens