Do No Harm

Running head: Do No Harm

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! ! ! ! ! ! ! Do No Harm Evan J. Weinberg University of Toronto


Do No Harm

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Primum non nocere is the principle by which a clinician must operate. The practitioner has vested responsibility in whom they treat; to act in a manner that minimizes restrictiveness within the recipient’s setting and maximize quality of life. In this problem of optimization, a false dichotomy has formed. Proponents of “Freedom From Harm” practice non-punitive treatment methods that focus on positive reinforcement to modify behaviour; on the other end of the continuum, there are those who support the “Right to Effective Treatment”-as framed by Matson (1988), effective behavioural programs include punishment in treatment regimes. This is truly a contentious issue; there is a minority group who cannot give informed consent for treatment to either school of practice. Those within this group include: Children-the largest group, the mentally incapacitated, the developmentally delayed, the dementing, those who are catatonic, those who are incarcerated, and adults, children alike, whom brook a pervasive developmental disorder (PDD). For these individuals, who cannot give their informed consent for treatment, a surrogate decision maker must be employed, a proxy. Advocacy for the “Right to Effective Treatment” is the ethically sound approach to behavior modification when a proxy is needed to represent someone who cannot represent themselves; this methodology fosters, transparency in treatment variables, reduced exposure to treatment methods that prolong suffering, and a bimodal approach to behaviour modification (BM). To feel the gravity of this discussion, an examination of informed consent is required. Informed consent, as it pertains here, involves several facets which need to be discussed with the patient prior to the initiation of treatment. The essential qualities of the behaviour modification approach and reasonable replacements to the tabled intervention must be discussed.

Do No Harm To each recourse, the risks, benefits, and uncertainties that lie there within must be explained. This is the responsibility of the practitioner and are a relatively straightforward matter, competence withstanding. It is in the autological wording of informed consent where we find problems; what it means to be informed and who can give consent. To be informed is to have understanding of the implications pertaining to the treatment-consent is to agree to treatment after being informed. If the client does not understand what is being presented to her/him by the clinician, the client is not informed and cannot therefore give consent to to treatment; a proxy must be sought. The proxy represents the client and makes decisions in their best interest. A proxy does not want the recipient of BM experience discomfort beyond that of their severe selfinjurious behaviour (SIB), the target behaviour. The proxy rejects the clinician’s suggestion of using methodology from the “Right to Effective Treatment”, opting for a non-punitive methodology from the “Freedom From Harm” school. The “freedom from harm” school, told by Feldman (1990), raises the notion that a nonpunitive approach to BM produces better generalization and maintenance of goals without negative side effects. Contemporary reviews (Favell et. al., 1982; Gorman-Smith & Matson, 1985; Matson & Taras, 1989), have found the one-sided approach of reinforcement is less effective than a two sided-approach of reinforcement and punishment in the treatment of severe behaviour. The techniques used in the generalization of positively reinforced behaviour is theoretically and logistically applicable to the generalization of punishment effects. The finding made by Stokes & Baer (1977), explain these techniques as, the use of multiple exemplars, a common stimulus, and loose training. The negative side effects of reward were published in the Journal of Applied Behaviour Analysis; authored by Balsam & Bondy (1983), positive

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reinforcement requires a reinforcement stimulus, a reward; this rewarding of favored behaviour can lead to a reliance on the stimulus to elicit a behaviour. Furthermore, aggression, stereotyped behaviour, and problems attending to learning task were displayed by those undergoing reinforcement BM. Regrettably, punitive procedures are often carried out on those enrolled in positive reinforcement practices. Wells & Smith (1983) off handedly mentioned the use of physical restraint on an individual engaging in SIB. In the same journal, Richmond (1983) explicitly included such practice in his treatment regime. These inconsistencies in reporting scientific findings undermines BM research and progress. The contributions made by reinforcement BM cannot be despoiled, these techniques are fostering positive approach BM methods, of which are best suited for low severity target behaviour. In dealing with a sever target behaviour, like SIB, commonly displayed by those with an autism spectrum disorder (ASD), clients deserve the “Right to Effective Treatment”. Put best by Van Houten et al. (1988), clients should not be exposed to treatment methods which would likely be ineffective, causing the prolonged experience of suffering. The responsibility of the proxy is to act in the best interest of the client they represent; the expedient extinction of the target behaviour, which may be self-injurious, is that best interest. LaVigna (1987) sees the “Right to Effective Treatment”’s use of effective as narrow minded; consider client “B”. In a report by Weinberg (2015), A 17 years old, male, with an FSIQ 40, “B” displayed severe SIB and outward aggression, engaging in up to 80 SIB per hour and seven aggressive acts daily. His scalp picking exposed skull bone and harm caused to those around him was quelled only by physical restraint. “B”’s family was not involved, New Jersey’s Division of Developmental Disabilities’ Bureau of Guardianship Services had guardianship. Enrolled in the

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now Judge Rotenburg Education Center (JREC), “B” received a treatment package that included electronic deceleration of behaviour (EDB) to manage his severe SIB and aggression. EDB used electrodes attached to skin that delivered a discharge when engaging in target behaviour. Operational definition of one treatment was one application of EDB for one incident of the behavior to be decelerated. The discharge was reported as,”potent, and very unpleasant”. This punitive action was complemented by positive reinforcement, used when “B” displayed proper non-verbal communication. With treatment, “B”’s SIB was decreased significantly and replacement behaviour was increased significantly, as well as communication. An important caveat, Weinberg (2015) further reported, removal of EDB correlated with an immediate resurgence of learned behaviour and that,”BRI did a good job at keeping clients alive and teaching [client “B”] to live at BRI.” Given JREC now infamous reputation it could be concluded that is was the specifics of treatment packages, rather than the theme of punitive action, which made client “B” so reliant on EDB. Truly, however, no method is without pitfalls; a patient’s right to “Freedom from Harm” is needed to check and balance a patient’s “Right to Effective Treatment”. An effective treatment is a treatment that, includes a bimodal approach to BM-both punitive and non-punitive approaches, reduces exposure to treatment methods that prolong suffering, and fosters a complete reporting of methodology. For those like “B”, who cannot give their informed consent to treatment, the clinician and proxy need to work together, to get an approximative solution to optimization, and to firstly, do no harm.


Do No Harm

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Balsam, P.D., & Bondy, A.S. (1983). The negative side effects of reward. Journal of Applied Behavior Analysis, 16, 283-296. Favell et. al. (1982). The treatment of self-injurious behavior. Behavior Therapy, 13,529-554. Feldman, M. A. (1993). Balancing freedom from harm and right to treatment for persons with developmental disabilities. In A. C. Repp & N. N. Singh (Eds.), Perspectives on the use of nonaversive and aversive interventions for persons with developmental disabilities (pp 261-271). Belmont, CA: Wadswoth Publishing Company

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Gorman-Smith, D., & Matson, J.L. (1985). A review of treatment research for self-injurious and stereotyped responding. Journal of Mental Deficiency Research, 29, 295-308

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LaVigna, G.W. (1987). The case against aversive stimuli: A review of the clinical and empirical evidence. Paper presented at the Association of behavior Analysis 13th Annual Convention, Nashville, TN, May 1987. Matson, J.L. (1988, March 30). Statement of Philosophy and Goals. International Association for the Right to Effective Treatment. Matson, J.L., & Taras, M.E. (1989). A 20year review of punishment and alternative methods to treat problem behaviors in developmentally delayed persons. Research in Developmental Disabilities, 10, 85-104. Richmond, G. (1983). Evaluation of a treatment for a hand-mouthing stereotypy. American Journal of Mental Deficiency, 87, 667-669. Stokes, T.F., & Bear, D.M. (1977). An implicit technology of generalization. Journal of Applied Behavior Analysis, 10, 349-367. Van Houten et. al. (1988). The right to effective behavioral treatment. Journal of Applied Behavior Analysis, 21,381-384. K. Weinberg, personal communication, January 21, 2015 Wells, M.E., & Smith, D.W. (1983). Reduction of self-injurious behavior of mentally retarded persons using sensory-integrative techniques. American journal of mental Deficiency, 87, 664-666.