AbstractEthicsis a vital part of any caring profession, in particular for the behaviouranalyst working with vulnerable clients. The use of restraint procedures onclients who exhibit self-injurious behaviour is an intrusive but at timesnecessary intervention implemented by behaviour analysts. The use of anintrusive procedure requires ethical protocol which is set out in theguidelines set by the BACB and the ABAI, which guides safe practice andimplementation. IntroductionBehaviourAnalysts are bound by a set of ethical protocol which governs decisions regardingdoing the right thing, doing what is worthwhile for the clients and being agood behaviour analyst (Cooper, Heron & Heward, 2014).
The aim of thebehaviour analyst is to improve the welfare of the client, and acting withinthe ethical guidelines (BACB, 2017) will help to produce significant behaviourchange which is of social importance to the client (Hawkins, 1984). Theethical guidelines (BACB, 2017) ensure the behaviour analyst acts within theclient’s best interest, whilst maintaining the integrity of the field and beinga positive representation of ABA to the public. The beliefs and values of acommunity, the law, the individual’s personal beliefs and philosophies willshape the ethical code (Bailey and Burch, 2011). The ethical decision can bereached by asking what is right, what is worth doing and what does it mean tobe a good BCBA (Cooper, Heron & Heward, 2014).
Behaviouranalyst often work with vulnerable client populations and as a result willencounter different ethical dilemmas throughout their career (Bailey &Burch, 2011). It is important that the behaviour analyst carries out theirethical decisions keeping in mind what is the best for each individual client,ensuring that all behaviour modification is functional for each client and mostimportantly is that the behaviour analyst does no harm (Cooper, Heron &Heward, 2014). Good ethical practice can be difficult as predicting the fullextent consequences of a selected intervention is not possible.
It is importantthat the chosen intervention is the most effective and least intrusive for theindividual. It is also interesting to look at how this intervention can be fadedin the future, so the client can achieve further independence.Thebest practice and least restrictive procedure is an important component ofethical behaviour.
The intervention should be designed, applied and evaluatedscientifically. This evaluation will show the progress made by the client,allowing for the eventual fading out of the intervention. However, in thecircumstance where the client does not make progress, it is essential that thedata is reviewed, and modifications are made to the intervention. Thecollection of data in behaviour analysis is paramount in every aspect of thefield as it will ensure the client’s best interests are upheld (Bailey , 2011) DiscussionChallengingbehaviour can present in the form of self-injury, which can pose a serious riskto the client depending on the severity of the behaviour. The use of physicalrestraint over the years has raised concerns regarding the restrictive natureof the practice (Vollmer, et al.
2011). The social acceptance of physical restraintincreases with the severity of the behaviour (Witt & Elliot, 1985). Thebehaviour analyst has a responsibility to the client to use the most effectivebut least intrusive behaviour interventions (BACB, 2017) (Cooper, Heron , 2014). The guidelines for implementing a punishment procedure advisethe behaviour analyst should first attempt to utilise reinforcement procedures,however in the case of serious problem behaviour it can require immediate useof punishment procedures, such as restraint (BACB, 2017).
Theuse of restraint to physically prevent the individual from causing significantharm to themselves or to others should only be considered for behaviour whichwould cause serious physical harm to the individual or those around them.Behaviours which occur in an unpredictable manner or behaviour which persistsafter the implementation of alternative procedures have been unsuccessful orinsufficient in reducing the behaviour. (Vollmer, et al. 2011) Thedecision regarding a restraint procedure should be made by the professionalteam, the client (if possible) and the guardians of the client. The use ofrestraint should be decided by a professional team with previous knowledge orexperience of the procedure, with the information provided by research the currentresearch the team can make an informed decision as to whether theimplementation of restraint is in the interests of the client.
The interests ofthe client should also be paramount in the decision-making process. Informedconsent is required for all behaviour modification programmes, and due to therestrictive practice in restraint interventions, it is vital that the clientand their guardians are a part of the decision-making process. With a previousclient who had very complex challenging behaviour, her guardian consented forus to perform the restraint procedure at the clinic, but her guardian did notwish to undergo training to perform the procedure at home. The guardian wasaware of our requirement to keep the client safe, but felt she could manage thebehaviour less restrictively in the home environment. The guardian had theright to make this decision and it was important ethically that we respectedthis decision.Ina previous work setting, team teach holds were implemented for clients whoengaged in high levels of self-injury. It was decided to use the holds because of the high-risk to the clients,regardless of the antecedent.
However, in some individuals it became apparentthe hold was becoming reinforcing as a form of escape, for example a childwould engage in self-injurious problem behaviour when the response effort washigher, which would then result in them being placed in a hold in a separatepart of the classroom until the client was no longer aggressive, whichfacilitated escape from the demand, the table for what could be upwards of anhour. Whilstworking with the client I found that the intensity of the self-injuriousbehaviour had decreased dramatically, for which I felt the team teach hold (aseated, double elbow hold) was unnecessary and unethical as the behaviour wasnot causing a huge detriment to the client. I also found that the client wouldengage in the problem behaviour and then prepare for the hold by grabbingeither myself or a colleague, suggesting that he was finding the holdreinforcing through the escape of the demand.
Afterspeaking to my supervisor and the BCBA responsible for the program she agreedthat we should attempt to remove the hold and instead block the self-injury, byguiding the client to clasp his hands. This was consented to by the client’smother as she did not implement the hold at home and would prefer a lessintrusive method. At first the behaviour had an extinction burst, where theclient engaged in challenging behaviour against other clients and other membersof staff. However, the behaviour gradually reduced to a rate lower than when wehad been implementing the hold.
Thisallowed for a greater quality of life for the client as he was no longer beingphysically restrained and the procedure at both school and home was identical,and manageable for his guardian. Thedisadvantage of implementing the restraint procedure is that it can potentiallymask the function of the behaviour (Borerro, et al, 2003) In my former workplace what we found was that while initially the hold would be implemented toprevent harm to the client, it was difficult to then move beyond the hold andattempt to find a different, effective treatment. As a client grows older, andconsequentially stronger, it becomes more difficult to implement a hold safely,which is why it is so essential to find an alternative, effective treatmentbefore this occurs.
Accordingto the Association of Behaviour Analysts International “procedures whichinvolve the use of restraint or seclusion should only be continued if they aredemonstrated to be safe and effective: their use should be reduced andeliminated when possible” (Vollmer, et al. 2011). This would imply that whilstwe are implementing restraint procedures we should be taking data and ensuringthe quality of the procedure, whilst aiming to decrease and remove therestraint. The collection of data on how often, under what antecedent and thelength of each restraint should be collected and used to make viable decisionsabout the procedure. Afterspeaking to ABA professionals regarding the removal of a restraint procedure,there seems to be no ethical or agreed upon protocol for carrying this out.
Itwas suggested to me that if there was a reduction of time in a hold,consequentially this could cause an increase in the target behaviour whichwould then make the previous, for example five-minute hold, restraint procedureineffective and would then require an increase in the duration of the hold. Thedifference between this professional’s background and thus what governed theirethical practice is that in their country it is legal to restrain an individualover the age of eighteen, whilst in the U.K. and Ireland it is a morecomplicated grey area, which is a legality that should govern the ethics ofprofessionals. Inthe case of another client who had team teach hold implemented for highintensity self-injury, they became to strong to physically restrain, even inthe presence of five qualified professionals and the decision was made toremove the hold.
Unfortunately, due to the effectiveness of the hold whilst theclient was younger, no further intervention had been made regarding the problembehaviour and the client was still on a variable ratio of one for simplenatural environment targets. In this scenario, it became apparent that the holdhad been used for convenience to staff rather. Whilst it was important to keepthe client safe, it was convenient for staff which meant that they did not seekfurther behaviour intervention or support for this individual. Duringmy professional placements it has been an ethical issue for me implementingholds, particularly for children who are engaging in low intensity, but howeverstill self-injurious behaviour. Ethically, we are bound to protect our clientsfrom harm, but we should also be seeking a less intrusive method of keepingthem safe (Cooper, Heron & Heward, 2014) There have been numerous caseswhere physical restraint has proved useful and slowly been faded out, and theuse of emergency physical restraint is essential in terms of protecting ourclients from self-injury. However, in most adult placements there is areluctance and often a legal inability to use a physical restraint, which meanswe are potentially leaving our former clients in a precarious situation whenthey move on from an ABA school or clinic. ConclusionTheuse of physical restraint to prevent injury to the client when other procedureshave proven ineffective is the ethical decision to make (Vollmer, et al, 2011).However, it is important that when the initial use of emergency restraint ismade during the assessment of a client, that the professional attempts to movetowards a less intrusive practice.
It is important that the rights of theindividual are respected and their consent, or the surrogate consent of aparent or guardian, is sought before the implementation of a physical restraintprocedure. Ensuring the restraint procedure is at all times under review of abehaviour analyst and only implemented by those trained in the restraint system(e.g.
Team Teach, PCM Crisis Management). Overall,restraint procedures should only be implemented if proven to be efficient and safefor the client (Vollmer, 2011). It issuggested that when possible, the use of such procedures should be reduced ifnot completely eliminated. The suggestion that long term use of restraintprocedures could become reinforcing (Favell, et al. 1978) is another factor inwhy the continued collection of accurate and relevant data to guide the use ofrestraint procedures is essential for the welfare of clients.