Voices from the past: Comparing the rapid prompting method and facilitated communication

Abstract

Objective: This article briefly reviews the history and damage caused by facilitated communication (FC) and highlights the parallels between FC and the Rapid Prompting Method (RPM).

Background: FC involves a therapist (or facilitator) supporting the hand of a person with autism while a message is typed on a letter board. FC is widely acknowledged to be a pseudoscientific, unsafe, and unethical treatment for people with autism. RPM is a more recent intervention for people with autism that involves the facilitator holding and moving the letter board while the individual with autism moves their own hand. Those who espouse the perceived benefits of FC and RPM make strikingly similar claims of hidden intelligence and extraordinary communication abilities in people with autism following treatment.

Conclusion: Clients, proponents, and practitioners of RPM should demand scientific validation of RPM in order to ensure the safety of people with disabilities that are involved with RPM.

• Rapid Prompting Method
• facilitated communication
• intervention
• communication
• autism
• pseudoscience

Extraordinary claims require extraordinary evidence. – Carl Sagan

Introduction

People with autism, along with their families and the practitioners and researchers working with them frequently must endure the rise of a new treatment that, in the absence of scientific research, claims to have amazing and unprecedented benefits. Facilitated communication (FC) is one notorious example of this recurring pattern. Proponents of FC described individuals with autism as having extraordinary hidden communication capabilities that can be unlocked when a therapist (referred to as a facilitator) merely supports the hand or wrist so that a person with autism can type a message on a stationary letter board or keyboard [1]. The Rapid Prompting Method (RPM) is a more recent intervention for people with autism that involves the facilitator holding and moving the letter board while the individual with autism moves their own hand. Strikingly similar to the claims made by advocates of FC, those who espouse RPM claim that RPM is “the most direct and unlimited path to learning and communicating” [2]. Herein we argue that RPM and FC are so similar that the devastating and horrific consequences of FC are likely to occur with RPM. The purpose of this article is to briefly review the sordid history of FC and highlight the parallels between FC and RPM in an effort to elucidate the potentially harmful effects of RPM.

Historical overview of facilitated communication

At its inception in Australia in the 1980s, FC was a technique to aid individuals with cerebral palsy in communicating; its usage spread widely in the early 1990s, both geographically and across disability diagnoses, to include individuals with autism in the United States [3]. The instructions for facilitators implementing FC detailed various levels of physical support that involved the facilitator holding the hand or wrist of a person with autism to assist with typing [1]. The facilitation practices described by Biklen in his initial study of FC in Australia also included this note:

If a person is not communicating, is producing nonsensical communication, or is producing questionable or wrong communication (e.g. when you doubt the communication and believe that it might be you, the facilitator, who is initiating the choices of letters and words [emphasis added]), revert to set, structured curricula (e.g. fill in blanks, math drills). [1]

Despite these initial concerns about authorship, Biklen et al. proceeded with promotion of FC in the United States. Though lacking empirical support, FC was widely featured in the media and generated tremendous public interest [4]. Individuals with autism who had never been observed reading, writing, or typing were suddenly reported to communicate in elaborate writing via FC [3]. These messages occasionally included sarcasm and abstract thought [1], among other unexpected qualities.

The purported effects of FC were too good to be true. The disappointing truth came to light when “virtually all researchers found that the facilitators were literally speaking on behalf of the person” [3]. Horrifyingly, this revelation came after some families were already facing criminal charges for sexual abuse of their children based solely on accusations made via facilitated messages [5]. In many cases, criminal charges were dropped only after it was determined that information provided via FC gave “no more support to the validity of the alleged sex abuse incidents than data gathered via a Ouija Board” [6]. There is no way to estimate the anguish endured by these families. Even in the absence of false charges, FC violated of a number of personal rights of individuals with disabilities, including the rights to effective treatment, self-expression, and self-determination [3].

The people with autism and their families were not the only victims of the false hope provided by FC. The facilitators were also victims of this deceptive illusion because they were often unaware of their influence over the typed messages. When the true nature of the facilitated messages’ authorship was elucidated, many facilitators experienced tremendous grief and shame. Some even felt sufficiently shunned by the profession to leave it entirely [5]. FC is now widely acknowledged as a pseudoscientific, unsafe, and unethical treatment [4], [7], [8].

Rapid Prompting Method

Soma Mukhopadhyay created RPM and brought it from India to the United States in 2001 when she accepted a fellowship with the Cure Autism Now Foundation [9]. In 2004, Mukhopadhyay began working with the nonprofit organization Helping Autism through Learning and Outreach (HALO) with the intent of spreading RPM nationally [2]. HALO describes RPM as follows:

Soma® Rapid Prompting Method uses a “Teach-ask” paradigm for eliciting responses through intensive verbal, auditory, visual, and/or tactile prompts. RPM presumes competence to increase students’ interest, confidence, and self-esteem. Prompting competes with each student's self-stimulatory behavior, and is designed to help students initiate a response. Student responses evolve from picking up answers, to pointing, typing, and writing which reveals students’ comprehension, academic abilities, and eventually, conversational skills. RPM is a low-tech approach in that it requires only an instructor, student, paper, and pencil [10].

Soma Mukhopadhyay created RPM for her son, Tito, who has a diagnosis of autism. Tito Mukhopadhyay is credited with authoring two poetry books, a collection of short stories, and a book describing his sensory experience [11]. Subsequently, he has been featured in the media numerous times. Tito has appeared on 60 Minutes II [12] and CNN [13], among other news programs, as well as in trusted print sources such as the New York Times and Scientific American [14], [15]. Perhaps most impactful, RPM is the focus of a recent documentary narrated by Academy Award winner Kate Winslet called A Mother's Courage: Talking Back to Autism [16]. These media reports, articles, and movie generally emphasize the “mysterious” nature of autism, give some history, and explanation of RPM as a demonstration of how Tito is able to communicate, and offer his poetry as evidence, while mentioning only in passing that RPM does not have research to support it at this time [14].

The instructional procedures used in RPM share some components with existing research-based practices. For example, people receiving RPM begin by being prompted to select between two options presented on torn scraps of paper [10]. The RPM practitioner presents a fact such as “The chair is yellow,” then immediately follows that fact with a related question such as “Did I say the chair is black or yellow?” Two scraps of paper representing the spoken choices (e.g. one with “black” and one with “yellow”) are presented to the client, who is then prompted to respond [10]. The prompts are similar to common prompting techniques used in interventions such as discrete trial training and picture exchange communication, wherein individuals are taught to respond to directives and questions by pointing to or handing a card to a therapist when presented with an array of cards with printed words and/or photographs [17]. However, the key difference between prompting in interventions like discrete trial training and prompting found in RPM is the purposeful and systematic fading of prompts. RPM (like FC) does not require prompts to be faded [2]. At some point, RPM clients advance from being prompted to select between scraps of paper to spelling words using a letter board that is held by the facilitator [10]. HALO justifies the lack of prompt fading by asserting that “prompt dependency is preferable to no response” [2]. This acceptance of prompt dependence within RPM serves to increase doubt regarding the true author of the facilitated message.

In the video footage of Mukhopadhyay's work with students published on the HALO [10] website, students who are considered to be the most independent still receive a high rate of verbal, gestural, and physical prompts from Mukhopadhyay as she holds and moves the letter board on which the clients are said to type. This differs little from the procedures of FC. It is irrelevant whether the facilitator's unconscious bias and expectations are introduced via moving the person's hand to touch the letter board, as in FC, or moving the letter board to touch the person's hand, as in RPM. Further increasing doubt, the RPM practitioner is told to “be sympathetic” to how materials are placed or held in order to ensure student success [18]. Even the most well-intentioned practitioner might find it all too easy, perhaps even unknowingly, to extend this sympathy in moving the letter board to make certain that the student chooses what the facilitator thinks the student wants or intends to say [5].

When addressing the question of whether RPM is research-based, HALO misleadingly asserts that “it does not take scientific research to realize that children must be taught if they are ever to learn and improve” [2]. It is difficult to disagree that teaching is an integral component of education; however, the methods by which individuals with autism are taught certainly can and should be the subject of scientific research [19]. In her book on RPM, Mukhopadhyay [18] expresses gratitude to the families of her clients, who “could have waited for scientific validation of [her] method, yet they understood the importance of educating their children now”.

RPM lacks empirical evidence for any claims of educational efficacy or independent communication on the part of the student. RPM was briefly mentioned in a review of ineffective practices in special education, with the notation that it does not have scientific validation [20]. To date, exactly one peer-reviewed quantitative study (by Chen et al. [21]) involving RPM has been published. However, the authors of that study “defer, for the moment, the crucial question of whether the communications produced during RPM therapy are genuine” [21]. Chen et al. instead explore other aspects of RPM. Specifically, they coded videotaped sessions of Mukhopadhyay working with clients to measure indicators of joint attention, time spent on repetitive behaviors, prompt levels, and accuracy/complexity of answers. They found no significant relationship between correct responses and the student's demonstration of “engaged attention” [21] defined as the student looking either at the therapist or at materials (e.g. letter board) [21]. This raises obvious questions: How does the client know how to answer, what the answer options are, or where the letters are located if the client is not looking at the facilitator or at the moving letter board? Mukhopadhyay [18] writes that “if the lesson is properly individualized – based on the learner's open learning channels – then he or she will be successful […] the responsibility lies with the teacher”.

However, Chen et al. [21] explain this phenomenon in a different way. Specifically, they suggest that “direct gaze [at the facilitator or letter board] may actually inhibit the ability to respond correctly”. Chen et al. provide insufficient evidence to draw such a radical conclusion. Although unusual eye gaze behavior is well-documented in individuals with autism [22], [23], a tremendous amount of research has demonstrated that joint attention, eye contact, and eye gaze abnormalities can be ameliorated with existing research-based interventions and improvements in these behaviors are, in fact, associated with improvements in communication, social skills, and other desirable outcomes [24–26].

We offer a competing explanation as to why a person need not look at the materials to type a message during RPM. We believe that, like FC, the facilitated messages produced during RPM sessions are often the words of the facilitator speaking on behalf of the individual with autism. As such, the individual with autism may not need to look at anything in particular. Instead, they may only need to move their hand at random while the facilitator, perhaps subconsciously, moves the board to align letters for the message they believe the person with autism would say.

Regarding RPM's claim to have a teaching pace that matches the speed of the student's self-stimulatory behaviors [2], Mukhopadhyay asserts that she is able to discover and utilize an individual's “dominant learning channel” [2]. The dominant or open learning channel theory suggested by Mukhopadhyay is an example of circular logic. Specifically, this seemingly scientific theory is touted as proof of how RPM works, and then RPM is given as evidence that these channels exist.

Comparing FC and RPM

The literature that promotes FC is characterized by findings of “unexpected literacy” [27]. Similarly, the researchers of the only RPM study to date stated that “those with autism may have highly developed, yet latent, intellectual abilities that are not tapped by many experimental paradigms” [21]. Such fantastical claims are warning signs for pseudoscience. FC meets 8 of the 10 criteria that can be used to identify pseudoscientific practices [7]. Specifically, FC: (a) is untestable because the research process breaks the trust between the client and facilitator, (b) has not changed even though evidence has been shown against it, (c) is promoted with only the evidence that seems to prove its effectiveness, (d) relies largely on anecdotal accounts to support its practice, (e) has inadequate evidence to support its claims, (f) is inconsistent with what is known about communication by people with developmental disabilities, (g) makes extraordinary claims about possible outcomes, and (h) is said to make sense only within a “vaguely described holistic framework” [7]. The two criteria for pseudoscience that FC does not meet are (i) avoidance of peer review and (j) use of unscientific terms [7].

When the same criteria for identifying pseudoscientific practices are applied to RPM, the analysis yields the same conclusion: RPM appears to be pseudoscientific. One notable difference between FC and RPM is that FC was researched extensively, whereas proponents of RPM denounce the scientific process and avoid peer review. Specifically, there are many impediments to ensure RPM is difficult to research. For example, videotaping the RPM session of one's own child is forbidden without express written consent of HALO, and in the event that this consent is obtained, videos are only permitted to be shown to immediate family [2]. Professionals who would like to observe an RPM session are required to pay an undisclosed observation fee [2]. Recording presentations on RPM by Mukhopadhyay is forbidden [2]. Although HALO does not directly state that RPM is not able to be tested scientifically, the organization appears to dismiss such questions categorically and points to the sole study of RPM as conclusive evidence [2]. Anecdotal reports in support of RPM, on the other hand, are abundant. The HALO [28] website is filled with testimonials, case studies (not to be confused with single-subject research), and photographs of clients. The evidence offered in support of RPM does not come close to meeting the size of the claims made regarding its outcomes.

While HALO [2] and Mukhopadhyay attempt to distance RPM from FC, on examination it appears that RPM may be the current façade of deceptive practices purporting to aid individuals with autism spectrum disorders in communicating. Mukhopadhyay [18] does acknowledge the “risk of using facilitated communication (when the teacher physically touches the learner's arm/elbow/shoulder while the learner is communicating)” in the process of transitioning to letter board usage. The fact that letter boards can be more easily moved than someone else's hand or wrist is either unrealized or ignored by the proponents of RPM.

Conclusion

FC is commonly seen as the epitome of deceptive and dangerous treatment because of its tragic history of depriving children with autism of the right to self-expression and for destroying families with false accusations of abuse. Clients, proponents, and practitioners of RPM should demand scientific validation of RPM in order to ensure the safety of people with disabilities receiving RPM.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.