REMEDIATION OF COMMUNICATION PROBLEMS THROUGH FACILITATED COMMUNICATION TRAINING: A CASE STUDY

Rosemary Crossley

DEAL Communication Centre, Victoria, Australia

ABSTRACTS

Facilitated communication training (FCT) is an educational technique intended to allow people who cannot speak or sign fluently to develop the hand skills necessary to use other non-speech communication strategies. It involves support to the arm, wrist or hand of the student, who is thus enabled to control his pointing, and has recently been the subject of considerable debate. Critics of the technique have cast doubt on the existence of any language problem remediable by touch. This study discusses the case of a person who had a language problem that did not appear to be connected with overt neuromotor impairment, was not accompanied by behavioural disturbance, and was remediable by touch alone. The case raises some interesting questions about the relation of physical prompts to language use.

L'entraînement à la communication facilitée (Facilitated communication training - FCT) est une technique éducative destinée á permettre á ceux qui n'ont pas les moyens de s'exprimer couramment per la parole oit par signes de développer les automatismes de leurs mains qui leur permettront d'utiliser d'autres stratégies de communication indépendantes de la parole. Le procédé consiste á soutenir le bras, le poignet ou la main de l'apprenant qui est ainsi capable de contrôler la direction dans laquelle il pointe,- récemment ce procédé a été l'objet d'une controverse considérable. Ses critiques ont mis en doute l'idée qu'il existe un problème de langage auquel on puisse rémédier par le toucher. Cette étude traite du cas d'une personne souffrant d'un problème de langage qui ne semblait pas lié à un déficit neuromoteur évident, que n'accompagnait aucun trouble du comportement, et auquel seul le toucher pouvait porter remède. Ce cas soulève des questions intéressantes sur le rapport entre le guidage physique et l'utilisation du langage.

Vermitteltes Kommunikationstraining ('facilitated communication training'= FCT) ist ein Unterrichtsansatz, der das Ziel verfolgt, Menschen, die weder flüssig sprechen noch flüssig zeichnen können, den Erwerb von gesturalen Handfertigkeiten zu ermöglichen, die fur andere nichtverbale Kommitnikations-strategien nötig sind. Es beinhaltet das Stützen des Armes, des Handgelenks oder der Hand der Person, die so in der Lage ist, ihre Zeigegesten besser zil steltern. Die Methode ist in letzter Zeit in beträchtlichem Maße debattiert worden. Kritiker der Methode haben die Existenz von Sprachproblemen, die durch Tastsinn zu beheben wiren, in Frage gestelit. In dieser Studie wird der Fall einer Person mit einem Sprachproblem vorgestellt, das zil keiner erkennbaren neuromotorischen Störung in Beziehung stand, mit keiner Verhaltensstörung in Zusammenhang zu bringen war und allien im Tastbereich behoben werden konnte. Der Fall stellt einige interessante Fragen hinsichtlich der Beziehung zwischen physischen Stimuli und Sprachverhalten.

Key words: facilitated communication training (FCT), remediation.

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INTRODUCTION

Facilitated communication training (FCT) is an educational technique intended to allow people who cannot speak or sign fluently to develop the hand skills necessary to use other non-speech communication strategies. One person (the facilitator) provides support to the arm, wrist or hand of another person (the student) who is thus enabled to control his pointing sufficiently to select objects, pictures, words or letters (Biklen, 1990; Crossley & Remington-Gurney, 1992). It has recently been the subject of considerable debate by parents, therapists, care workers, and psychologists and it has been suggested that all the messages produced by use of facilitation come from the facilitators and not from the students. 'The literature on this issue is by now considerable. Reviews of this literature have reached negative (Hudson, 1995) and positive (Biklen, Saha & Kliewer, 1995) conclusions on the value of the method. Studies are continuing to appear (Cabay, 1994; Simon, Toll & Whitehair, 1994; Smith, Haas & Belcher, 1994; Vazquez, 1994; Biklen, Saha & Kliewer, 1995; Crews et al., 1995; Janzen-Wilde, Duchan & Higginbotham, 1995; Olney, 1995; Baldac & Parsons, 1997; Cardinal, Hanson & Wakeham 1996).

Critics of FCT have cast doubt on the existence of any language problem remediable by touch. Prior and Cummins (1992) write:

There are some curious aspects of facilitation that need explanation. It is unclear why physical contact, even if minimal, is necessary for clients to communicate after their ability to communicate has allegedly been established and they have become willing and able to do so. (p. 333)

and:

In fact, an explanation for all these peculiarities can be found in the proposition that the success of facilitated communication has very little to do with emotional support, as suggested by Biklen, and very much to do with physical control by the assistant; either in the form of overt control of the client's movements or by supplying covert clues which are used by the client to control his or her movements.

If such an argument was to be accepted then the following anomalies recorded by Biklen would have a simple explanation.

1. The continuing dependence of clients on minor physical assistance even though they may express a strong desire to communicate... (p. 334)

In most instances where FCT is used, the question of the function of touch is complicated by other considerations. The client may have obvious neuromotor problems which are addressed by facilitation, such as low muscle tone, difficulty isolating an index finger, impulsivity or perseveration (Crossley & Remington-Gurney, 1992). When such problems exist the facilitator needs to carry out specific remedial practices, such as restraining the unwanted fingers to help the student to achieve index finger isolation. If facilitation is successful in enabling the student to use a communication aid effectively it is impossible to separate the effect of touch alone from the effect of whatever specific facilitation strategies are used. It would be illuminating, therefore, if any case existed where a client had a language problem that did not appear to be connected with overt neuromotor impairment, was not accompanied by behavioural disturbance, and was remediable by touch alone.

CASE STUDY

In early 1992 1 received a letter from Canada:

My name is Sarah S. I have very severe learning disabilities which were discovered when I was 9.5. Up to that time it was thought I was 'slow'. Right now I am using facilitated communication. Better yet, I am using an electric device to facilitate myself.

The letter was typed. It went on:

Tis is a peregraf ritin withot fc and, I rote it so yuo cude see how I spel and rite normily. wile I was a grejit studin at the unvresty of jorju a sikitrit asesd mre as heving otism. My sokirterst here in Toromgto beleeves I hav pdd- this semes verey liilley, bsat on my lernimg and soshel skils and defsetes ares. I hpoe this letre has bene of imtrest to yoo and tath yoku wil rite to me...

Sarah wrote the last paragraph out again, in handwriting, with facilitation:

This is a paragraph written without fc, and I wrote it so you could see how I spell and write normally. While I was a graduate student at the University of Georgia, a psychiatrist assessed me as having autism. My psychiatrist here in Toronto believes I have PDD - this seems very likely, based on my learning and social skills and deficit areas. I hope this letter has been of interest to you and that you will write to me...

Sarah was, as she said, a graduate student, could talk clearly and fluently, and as such was well outside the usual range of clients using FCT, which has so far been reported as having been successful in cases of very severe communication impairment in people with cerebral palsy or Down's syndrome, or diagnosed as intellectually impaired or autistic. She was, in the unpleasant phrase used in the autism area, 'high functioning'.

As her letter indicates, however, Sarah did have an obvious and severe language problem; she had great difficulty reading, and her writing was so misspelt as to be almost unreadable.

Sarah's parents had noted that at the age of two she would sit and twiddle her hands or spin, and that she had echolalic speech. At the age of nine-and-a half she was, for the first time, taken to a psychologist who initially favoured a diagnosis of mental retardation but on having her mathematical skills demonstrated to him substituted a diagnosis of severe learning disorders. At a later stage, Sarah was also diagnosed as having schizoaffective. disorder because of occasional hallucinations, and this had been treated with medication. Her present psychiatrist believed her to have pervasive developmental disorder. Sarah had some autistic features; she still liked to spin, for example, and a chair had been constructed by an electrical engineer that would revolve her at 80 rpm to relax her when she felt nervous.

Sarah had progressed through school and university by having her books read to her and dictating assignments so that she did not have to write. After graduating she was introduced to FCT. About a year before the date of her letter Sarah had been involved in a programme for autistic children - as a helper, not a client. FCT was being used by some of the children attending the camp, and the staff had thus given the helpers information on the method. As part of the helpers' training they had to practice facilitating one another to spell. When another helper held Sarah's wrist her spelling suddenly straightened out, going from grade two to an educationally appropriate level:

Sarah
It was like a lightbulb came on. Like, wow! I can think! It scared me a bit, because it meant that there were things in my head I didn't know I had.*

Three weeks after Sarah had first been introduced to FCT, she was using it to communicate with eight people, including her psychiatrist and a 10-year-old girl. She required facilitation at different levels with different people, having been faded back to a mere shoulder touch with one finger from her friend, Denise, whilst still requiring wrist and elbow support from her psychiatrist.

She had an absolutely clear 'on' and 'off'. If a familiar person touched her shoulder lightly with a finger, Sarah could spell. If that person took the finger away she would spell the same word wrongly and, furthermore, she would not be able to tell by looking at them which of the two written words was correct until the finger was once again put on her shoulder. On a video, made in May 1991, for example, Sarah is seen spelling 'preshere' without FCT and 'pressure' with FCT.

Sarah's initial instructions to new facilitators were:

Take my hand - apply a little pressure so I have to push down - Every time I do a letter I want you to lift my hand so I don't perseverate on that letter. (1)

She described the qualities of a good facilitator:

Apply medium amount of pressure
Someone I trust
Not sceptical
The more I trust the person, the more our bodies become one - I go further into the brain.(1)

On a videotape, Sarah described, with and without facilitation, the effects of FCT

Sarah (without facilitation)

I am alsoe abell to rtuehre weds thots and idess that I cante withoute fasetld camikshun (I am also able to retrieve words, thoughts and ideas that I couldn't without facilitated communication).


(with facilitation)

It feels like getting into my brain passages, opening up thoughts I didn't know I had. (2)

Sarah said that the areas that were most assisted by facilitation were in answering questions that have emotional content to them and in word retrieval. Anything that had an emotional context had previously been difficult. In talking with her psychiatrist, it had been usual to have five-minute pauses; with facilitation, these had gone, and she was able to discuss her dreams for the first time. More specifically, she was able to access words (and information) much more efficiently:

Sarah

[I use facilitation] ... so I don't get stuck on words... Sometimes even on the communicator I can't retrieve a word but I can retrieve a sentence that adequately describes the word - without that Denise has to supply the word -

Denise

I don't play fill-in-the-blanks any more. (3)

Sarah

I actually have the words in my head but I can't get it out.

Sarah also provides some clues to the favourable behavioural effects reported in other studies:

Sarah

I really like it because now when I wake up crying from a bad dream instead of being able to say a few things about the dream I can say what it felt like

Denise

And what it meant to you -

Sarah

And I can calm down.

If Sarah had been able to show improved spelling only when facilitated the explanation would still be open that she was wittingly or unwittingly manipulated or cued by the facilitator, as has been suggested in other cases involving FCT. However, Sarah had also (as she said in her letter) gone on to build a device to do the facilitation. When she had reached the stage where her typing could be facilitated by 20 people, including her psychologist, her speech pathologist, friends, educators, camp leaders, and several children, she thought there might be a way in which she could facilitate herself. As sometimes all she needed was a touch on the shoulder, Sarah asked a biomedical engineer to make up a small vibrating machine on a strap to go over her shoulder.(4) That worked too. When it was on and buzzing, she could spell; when it was turned off she said she could not. When it was turned on Sarah could understand idiomatic expressions and metaphors; when it was turned off, she said she could not.

Sarah's general fluency also increased when facilitated by the device. When asked on a second video (made in October 1991, after the introduction of the device) to say what her favourite summer activity was, Sarah typed, without facilitation, 'Campfires'. Asked by the interviewer 'Why do you like campfires?', she answered 'They're warm'. Asked by the interviewer 'Why is that different from having the heat on?' Sarah answered 'They're comforting'. When Sarah was asked the same question with the device on she spelled:

Campfires, and taking care of kids. I like singing songs and roasting marshmallows and playing with kids, kids I like because it's fun to work with them and help them grow.

When I eventually met Sarah at a conference in Toronto in 1992 I asked her to do some spelling with the buzzer off and on. When the buzzer was turned on 'Ostrayluyuh' was corrected to 'Australia' and 'tok' to 'talk'.

I tried her out reading facial expressions. I gave a broad smile; with the buzzer off Sarah said I was angry, and with the buzzer on, she said it was a smile. I tried to look angry. With the buzzer off Sarah could not read it at all, with it on she said 'anger'. I tried to look quizzical (not an easy one). With the buzzer off, 'don't know'; buzzer on, 'confused', which was close. I crossed my eyes to see if Sarah could recognise a facial change that did not express emotion; with the buzzer off, 'I don't know', and with it on 'You've crossed your eyes'. Sarah appeared to interpret social signals better when facilitated by the buzzer.

I tried her on intonations. When I said 'What are you doing here?' Sarah thought that meant 'You like me'; with the buzzer on, she interpreted it as 'You don't want me here'. If I said, 'What are you doing here?' she thought that that emphasis meant 'You don't like me' until she turned on the buzzer and interpreted it as 'You're surprised I'm in this place'. If I said 'What are you doing here?' Sarah said she did not know what I meant until she turned on the buzzer, when she interpreted it as 'You don't know why I am here.'

Disappointingly, Sarah's machine has not, as far as I know, worked any instant marvels on any other people using FCT-, in general, they have much more significant disabilities, have much further to go to attain independent typing, and in many cases, do need physical support or a check on perseveration. Some centres using FCT are still experimenting with the device, and may yet find someone who will respond. Sarah herself has outgrown it. Some months later she wrote to me that:

I have some exciting news - the facilitation is affecting me somehow and I can communicate in written form just a bit better WITHOUT facilitation.

After using the device for more than a year, Sarah had found that she did not need it any more. Her eventual discarding of facilitation might suggest that her problems were psychological rather than neurological in the first place, if such a division is possible, but I do not believe that this is a necessary conclusion.

The obvious question is what the device could have done for Sarah that would explain the differences in her performance. What human facilitators did was, in some respects, straightforward. At the beginning of FCT, Sarah required her facilitators to provide some resistance, to slow down her typing, and to move her hand back after she had hit a letter, to prevent her repeating letters or hitting extraneous letters. It then gradually became automatic for her to withdraw her own hand.

During this learning stage, the level of support needed for Sarah to achieve fluent typing varied between facilitators and situations, with least support being required from her best friend and most from her psychologist. It appears that Sarah's ability to monitor and control her own performance was improving but was still vulnerable to stress. By the time the vibrating device was made, Sarah could type reliably with only finger-to-shoulder contact with most partners in most situations. What did that touch do?

One hypothesis is that it (and the human contact that preceded it) helped Sarah to attain and maintain focus and monitor her own performance.

Decoding print was difficult for Sarah whether or not facilitation was used, and whether the device was on or off. When I met her, Sarah was still involved in working with children with autism, and facilitating them to spell. They spelled at their own level, good or bad (but generally better than her), whether or not she was using the buzzer. I asked the obvious question: could she read what they were typing?

'Yes' she said, she could read it. 'I think it's because it's one letter at a time.' This suggested a possible solution. I spelled out aloud to her, a letter at a time, 'C A N Y 0 U U N D E R S T A N D M E.' Sarah repeated 'Can you understand me?'

Her letter-by-letter decoding was evidently better than her block decoding. From a practical point of view, however, having things read out letter by letter was no kind of improvement on having them read out word by word, so we had to give attention to Sarah's actual reading processes. I obtained a document with large print, put it in front of her, tore a hole in a sheet of paper to make a screen, and moved over the word NEWSLETTER, letter by letter. Sarah said each letter under her breath and then said 'Newsletter'. I made another, smaller screen and we went over the word challenging in the same way. Sarah said 'challenging'. It was obviously a promising technique. Unfortunately, I was leaving for Australia and was unable to investigate this further, but Sarah and Denise persisted with the technique. The same progression to independence occurred with her reading as with her typing. Sarah started with a one-letter screen, sliding it along lines of text, and found that it worked very well. Her friend, Denise, telephoned me to say that for the first time ever, Sarah had been able to read a letter to her over the telephone rather than, as previously, telephoning her to ask her to come over and read it aloud.

After about a year of using the screen, however, Sarah found that she no longer needed it.

DISCUSSION

Sarah's problem may have been, at least in part, pacing. Her normal scanning speed appeared to have been too fast for her to decode print, and she had been unable to adjust her scanning speed without a device which forced her to do so. It is sometimes necessary in computer programming to insert an instruction or subroutine which has no function except to interrupt the execution of that part of the program sufficiently to allow time for other necessary functions to be performed. If Sarah's typing problems were due to her speeding up beyond her ability to self-monitor then it may be that the rhythm provided by the vibrator enabled her to maintain a functional speed, pacing her as an interrupt paces the computer. Oliver Sacks (1991) talks about the importance of rhythm in a number of contexts; Miss D, for example, a Parkinsonianism patient:

Miss D had found that regular blinking, or a loud-ticking watch, or horizontal lines or marks on the ground... served to pace Sacks' italics] her, and to prevent the incontinent hastenings and retardings which otherwise marred her ambulation. (p. 63)(5)

I am unable to explain the effect of the vibrating device on Sarah's decoding of intonation and facial expressions. It is possible that an explanation will eventually emerge from the work on somatic markers of Damasio (1994) and his colleagues.

Sarah's introduction to FCT was an extraordinarily unlikely combination of circumstances. It raised some extremely interesting questions about the relation of physical prompts to language use, and it generated a number of hypotheses. The case does, for example, seem to demonstrate that language difficulties remediable by touch do exist. Sarah had either been playing a complicated practical joke for 20 years or she did have some form of language dysfunction. She could circumvent it with physical contact from another person. The amount of facilitation was minimal, but it was essential. The effect was also independently demonstrable. Cummins and Prior (1992) say that:

... there are clear inherent dangers in the interpretation of communications elicited using even minor physical contact. (p. 233)

If there was any question of any person moving Sarah's arm or cueing her to the letters it was possible to ask her to confirm in speech that the movement was hers. If it was suggested that she might have been cued unwittingly and accepted the cueing, the introduction of the mechanical device makes even that explanation unfeasible.

Sarah's machine might not provide the explanation sought by critics of FCT as to exactly why contact was necessary to her communication, but it was certainly a demonstration that contact did have a role to play. Furthermore, whatever the buzzer did for her plainly had little or nothing to do with emotional support, and so that could not be the only factor in the treatment. Neither Biklen (1990, 1992) nor I have ever suggested that emotional support was the only factor in facilitation, but a number of critics have attributed the suggestion to us nonetheless:

The proponents of the method may respond that it is the emotional support that is critical in their physical assistance, but they provide no explanation for the fact that even after 2 years of such support no independent communication appears possible. (Prior & Cummins, 1992, p. 334)

One of the problems with many critics is that they seem to want the explanations to come before the observations.

Sarah's problems with perception when unfacilitated raises the possibility that some people with severe communication impairments have not only expressive language difficulties partially remediable by facilitation but also receptive language impairments that are more severe when the person is not being facilitated. It is difficult to know how common such a problem is among people using FCT. It is possible to establish its existence with Sarah only because she has spoken and written output in the unfacilitated state that can be used to check on the facilitated output. Few of the people now using FCT have any controllable unfacilitated output at all, and thus we have no means of comparison between their 'on' and their 'off states except by asking them when they are being facilitated what it feels like when they are not. This would be a particularly hard question for Henry James, let alone the typical person using FCT!

In Sarah's case, it appears that facilitation helped her word-finding, as well as her spelling. This is a significant finding, because the existence of word-finding problems in FCT users has previously been doubted on the grounds that the evidence for the existence of word-finding problems in these people relied on the validity of their communication whilst facilitated and was therefore suspect (Hudson, 1995).

Doubt has been cast elsewhere on the use of facilitation because of 'Puzzling... differences in the level of language sophistication elicited via assisted communication and that produced when not assisted' (Prior & Cummins, 1992, p. 334). Sarah's communications in the two modes do show some differences in level of complexity.(6)

There is a limit to the conclusions that can be drawn from a single case, but it can at least be said that any language problems that have been demonstrated in even a single case cannot thereafter be ruled out as impossible a priori. Sarah's success offers few explanations, but it may help us to frame the questions.

Sarah's particular combination of circumstances is, of course, extremely uncommon. It is not necessarily obvious that her underlying 'problems are as rare. The difference between Sarah and most other people with severe communication impairments may be that she has primarily reading and writing difficulties and only minor speech difficulties. Most other FCT users have both more severe reading and writing difficulties and very much more severe speech difficulties. The assumption that has traditionally been made is that 'reading and writing difficulties' are intrinsically different in kind from 'reading and writing and speech' difficulties, and that 'reading and writing and speech' difficulties are intrinsically different in kind from the combination of 'reading' and 'writing' and 'speech' difficulties - that each presentation is its own condition. This assumption is suspect.

The remedies Sarah has found may not be applicable even to other people with similar conditions, but her experience constitutes a limiting case. Because of her pre-existing communicative competence Sarah was capable of validating her own communication in a manner impossible for many other people who use FCT Her disability has resulted in the smallest possible increment of communication disorder(7), and her facilitation is not only the least but also the purest that can be devised. The buzzer did not offer her emotional support, or support against gravity, or pull back her hand after hitting a letter. It did something different and harder to define or explain. This means that whatever else FCT does to help anyone else communicate it might also be doing that undefinable thing.

Sarah's experiences have ramifications going well beyond the circumstances of her own case. Her case does, however, establish that there do exist language disorders that are susceptible to remedy through touch. It is not an argument against the use of FCT that the function of touch has not been explained. The range of possible neurological dysfunctions in the human mind cannot be limited by any requirement to be immediately explicable by registered psychologists.

Notes

(1) These passages are transcribed from videotape. The procedure was that Sarah would spell out a message on a Canon Communicator, a mini-typewriter with paper tape output, after which her communication partner, a speech pathologist, would read the message word by word to the camera. Precise spelling is thus unknown.

(2) This passage is transcribed from videotape. Here, the procedure was that Sarah spelled out a message on a communicator, after which her communication partner read the message letter by letter to the camera. Precise spelling is thus as given.

(3) By 'fill-in-the-blanks', Denise means offering words suggested by context when Sarah encountered a word-finding problem.

(4) Sarah could adjust the vibration rate to her optimum level.

(5) Sarah said that she had found by accident that her gait improved when she had the vibrator on. This was most obvious on stairs, she said. We checked this out in the foyer of the World Trade Center, with Sarah going up and down the stairs while the biomedical engineer who had designed the device and I watched to see if there was an observable difference that could be reliably associated with the device being on or off. The difference was small but perceptible. Without the device Sarah moved a little jerkily - not enough to attract attention in the street, but noticeable if you were already looking. With the device on, her movements smoothed out, became easier and more graceful. Sarah had not noticed, but we did, that when the device was off she looked down at her feet and the steps much more frequently than when it was on.

(6) Critics, of course, raise a number of other objections not addressed in this paper. For examples of such objections and the responses to them see Biklen (1992) and Cummins and Prior (1992).

(7) The smallest, at least, that can be clearly distinguished by our existing tests.

References

Baldac S, Parsons C (1997). Factors affecting performance in facilitated communication. In: D Biklen, D Cardinal (eds). Contested Words, Contested Science. New York: Teachers College Press.

Biklen D (1990). Communication unbound; autism and praxis. Harvard Education Review 60, 291. Biklen D (1992). Autism orthodoxy versus free speech; a reply to Cummins and Prior. Harvard Education Review 62, 242-256.

Biklen D, Saha N, Kliewer C (1995). How teachers confirm the authorship of facilitated communication; a portfolio approach. Journal of the American Speech-Hearing Association 20, 45-56.

Cabay M (1994). A controlled evaluation of Facilitated Communication with four autistic children. Journal of Autism and Developmental Disorders 24, 517-527.

Cardinal D, Hanson D, Wakeham J (1996). Validation of Facilitated Communication; an experimental study. Mental Retardation. 34, 231-242.

Crews W, Sanders E, Hensley L, Johnson Y, Bonaventura S, Rhodes R (1995). An evaluation of facilitated communication in a group of nonverbal individuals with mental retardation. Journal of Autism and Developmental Disorders 25, 205-213.

Crossley R, Remington-Gurney J (1992). Getting the words out: Facilitated Communication training. Topics in Language Disorders 12, 29.

Cummins R, Prior M (1992). Autism and assisted communication: a response to Biklen. Harvard Education Review 62, 228.

Damasio A (1994). Descartes' Error. New York: Grosset/Putnam.

Hudson A (1995).' Facilitated Communication: a critique. In: T Ollendick, R Prinz (eds). Advances in Clinical Child Psychology.(Volume 17). New York: Plenum, pp. 197-232.

Janzen-Wilde M, Duchan J, Higginbotham D (1995). Successful use of Facilitated Communication with an oral child. Journal of Speech and Hearing Research 38, 658-676.

Olney M (1995). Reading between the lines: a case study on Facilitated Communication. Journal of the American Speech-Hearing Association 20, 57-65.

Prior R, Cummins M (1992). Questions about Facilitated Communication and autism. Journal of Autism and Developmental Disorders 22, 33 1.

Sacks 0 (1991). Awakenings. London: Picador.

Simon E, Toll D, Whitehair P (1994). A naturalistic approach to the validation of facilitated communication. Journal of Autism and Developmental Disorders 24, 647-657.

Smith M, Haas P, Belcher R (1994). Facilitated Communication: the effects of facilitator knowledge and level of assistance on output. Journal of Autism and Developmental Disorders 24, 357-367.

Vazquez C (I 994). Facilitated Communication: a multi-task controlled evaluation. Journal of Autism and Developmental Disorders 24, 269-379.

Address correspondence to Rosemary Crossley, AM, M.Ed. DEAL Communication Centre, 538 Dandenong Road, Caulfield, Victoria 3162, Australia. E-mail to Rosemary Crossley <s9340099@cougar.vut.edu.au>

Received January 1995,- revised version accepted January 1996.

FACILITATED COMMUNICATION TRAINING: AN EVALUATION

Catherine Adams

THE CONTRIBUTION OF PSYCHOLOGY TO UNDERSTANDING THE REMEDIATION OF COMMUNICATION PROBLEMS THROUGH FACILITATED COMMUNICATION

Julie E. Dockrell & Christopher Sterling

A NEUROLOGICAL COMMENTARY

Lewis Rosenbloom

FACILITATED COMMUNICATION TRAINING: COMMENTS FROM A HEAD TEACHER

Pat Derbyshire

Unfortunately, permission has not been gained to reprint them here, and readers are referred to that issue of the journal. A general overview of the commentaries can be obtained from the published response.

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RESPONSE TO COMMENTARIES

Rosemary Crossley

The two longest commentaries on my paper are concerned with form rather than substance. Only a small proportion of Adams' response, and an even smaller proportion of the Dockrell and Stirling response, refers to Sarah and the issues raised by her experiences. Instead, the authors have provided detailed instructions on how to write case reports and multiple reasons to avoid engaging with the facts of this case. the reasons given are basically three:

* The data presented is insufficient.

* The outcomes lack a theoretical rationale.

* Alternative explanations for the data are conceivable.

The first point of insufficiency insisted upon is the absence of pretesting.

Adams, for example, says that:

... there is no data to support the claim of word-retrieval problems, other than anecdotal... there is no detailed investigation or analysis of the sort of reading and spelling deficits presented before the FC intervention... In order to pursue this it would be necessary to gather much more data...

The great eighteenth-century French chemist, Lavoisier, spent no small proportion of his time refuting quacks and charlatans. He was particularly hard on those deluded (or worse) individuals who peddled unscientific nonsense about rocks falling from the sky Some peasants said that they had seen lights falling from the sky on to spots which, when subsequently examined, proved to display craters at the bottom of which were rocks. Such people, said Lavoisier, had committed the elementary fallacy of neglecting the necessity of setting a baseline; as the supposed impact sites had not been examined before the event, it was impossible to rule out the possibility that the rocks had been there all along, being exposed only when a powerful lightning strike cleared away supervening soil.

It would, I agree, be useful to have more pre-intervention test data on Sarah's capacities. In the absence of a functioning time machine, however, there can be no such data. The question must thus be what can be learned from the information we have. Adams, and Dockrell and Stirling, all seem to feel that unless we have all the information we would ideally want about any given case, we can learn little or nothing from it and, presumably, should disregard it.

Despite Lavoisier's genius, he was wrong and the peasants were right. Meteorites do fall from the sky. More generally, Lavoisier was in error in attempting to impose laboratory protocols on inherently unpredictable circumstances. By their very nature, unpredictable cases can only come to notice after they occur. A knowledge system that filters out such cases on the basis of lack of preliminary data will be relatively proof against disturbance, but this is a qualified benefit.

Despite Sarah's culpable neglect of pretesting, however, it is nonetheless the case that the data provided in the paper is adequate for its limited purposes. If the paper claimed to prove that FC training remediated a specific communication disorder, it would be necessary to provide sufficient data to establish that Sarah had that specific disorder. If the paper claimed to prove that one specific form of FC training remediated communication disorders, more data would be required on the specific particulars of the intervention. As the paper only aims to show that there exist communication disorders that are susceptible to remedy through touch, the article has only to provide enough information to establish that:

• Sarah had a communication disorder.
• There was a successful intervention.
• The successful intervention did involve touch.

The information provided is sufficient to establish all three points.

The commentators stress the insufficiency of theoretical underpinning provided. Several of Adams' objections are made on this basis:

Crossley does not attempt to suggest why trained facilitators should have different effects on the same person...

Crossley offers no justification as to why a touch of a finger can have the effect... ... we would like at least some of the explanations to come with the observations.

I have not attempted to provide explanations for phenomena for which I have no explanations. However, theories are not essential accompaniments to observations. Apples fell before Newton provided us with an explanation. In the affairs of this world, and in our science, we must take into account both facts for which we have explanatory theories and facts for which we have, as yet, no such theories. The absence of a justificatory theory (or, indeed, the possible incorrectness of a justificatory theory) should be no barrier to the acceptance of a fact. Language disorders that are susceptible to remedy through touch exist. I appreciate any and all attempts to explain these phenomena, but their existence does not depend on my ability to account for them.

The commentators seem particularly eager to provide alternative explanations for Sarah's communication improvements, explanations that do not involve any contribution from FC. They seem to think, in fact, that simply hypothesising an alternative explanation - any explanation, however unsupported by the evidence - constitutes a conclusive refutation of any such contribution. Adams asks:

... has she found relief because she is now able to succeed in written language, or has a change in emotional state brought about a change in her ability to cooperate?

All of a sudden Sarah is able to write legibly... her confidence improves, and she links it with FC... Effects of confidence... are... familiar to the... clinician.

Could it be the case that she had matured to the point at which she was ready to make strides in her spelling and writing, for instance, of was she emotionally ready to confront her poor literacy skills?

In propounding their novel explanations for what happened to Sarah, the commentators have scant regard for Sarah's own opinions or abilities. The explanations adduced by Adams (above) go well beyond the data to imply that Sarah was previously uncooperative or immature. Derbyshire suggests that:

Sarah... is likely to have been unaware of the physiological resolution of whatever was underlying her range of difficulties and hence there was a genuine block to her being able to make effective use of skills...

Dockrell and Stirling ask:

Was anything else that could have contributed to Sarah's improvement happening in her life over this time?

... did the intervention work because... of the increased attention, social and emotional support that accompanies any therapy?

Facilitator interaction, confidence and the circumstances of the communication are important (and have frequently been disregarded by those attempting to test the communication of FC users) despite Adams' dismissal of their significance:

Do we not all touch in the same way, if the touch is defined as a finger on the shoulder. (Adams)

The same could be said of kissing, if a kiss is defined as the touch of a mouth on a face, but the choice of partner is nonetheless thought to be of some significance. Underlining the obvious, to say that touch affects something is not to say that it produces its effects in isolation. The person attached to the finger will inevitably affect the interaction, for better or worse, as will the content and circumstances of the intervention.

I can hypothesise that touch, human or electrical, operated as the equivalent of an 'interrupt' instruction to a computer, slowed Sarah's responses down, and allowed her time to retrieve and produce considered conventional spelling rather than the automatic phonetic approximations that she produced without facilitation. I can also hypothesise that discussing her problems with her male psyc hiatrist in his office was more stressful for Sarah than having coffee and a chat with her female flatmate, and that the effect of the interrupt varied in proportion to the amount of stress Sarah was under. But, these are merely possibilities, unsupported by evidence.

Although personal interaction, confidence and emotional support are important, the significance of Sarah's case, nonetheless, is partly that:

• The moral support of a human facilitator, however useful, was not essential, in that Sarah was able to reproduce the effect mechanically.
• Sarah's improvement was not solely due to increased confidence, in that she first detected the effect when learning to facilitate other people, and had not (before that moment) contemplated the possibility that facilitation could help her - any confidence followed the observation of improvement, not the other way about.
• Similarly, Sarah detected the positive effect of facilitation before she received any additional therapy-related attention or social and emotional support.

Suggesting that Sarah's improvement was due to some form of maturation effect that happened to coincide with her use of FC really is clutching at a straw. Not only is such a coincidence inherently unlikely, it does not explain what it is required to explain. To match the facts, not only is it necessary that something else could have contributed to Sarah's improvement happened at the time when a hand was first placed on her shoulder but also that (whatever that something was) it ceased two minutes later when the hand was removed and started up again a minute later when the hand was replaced.

The matter for which an explanation is required is not the improvement in Sarah's communication - this could be due to FC, to maturation, or to the phases of the moon. What must be explained is that Sarah's improvement turned on and off repeatedly at the precise second that facilitation was applied or withdrawn. If I flick a switch and the light goes off this may be due to my flicking the switch, or it may be that coincidentally power has failed at the station; if I flick the switch again and the light goes on, it may be that coincidentally the power failure has been repaired; however, within a finite number of switch flicks there comes a time when the power failure theory ceases to be the most parsimonious explanation for the observed sequence of events.

The general eagerness to devise implausible alternative explanations for which no evidence whatsoever exists seems to be related to a fear that should any points be conceded this would give aid and comfort to FC training, an intervention apparently seen as inherently unsound:

... the consensus is at present that there is no strong evidence to support the effectiveness of FC. (Adams)

There is, as it happens, no such consensus on FC training, the merits of which continue to be hotly debated. Those readers interested in the evidence are recommended to a forthcoming collection of research studies (Biklen & Cardinal, 1997) or to the articles for and against, cited in Biklen, Saha and Kliewer (1995). My article is restricted to Sarah's distinctive case and does not claim to prove any generalised effectiveness for FC training.

Even that restriction is not sufficient for Adams, who apparently wants to make the case history disappear:

Is not the final independence of Sarah evidence of the fact that she does not need FC and probably never needed it in the first place?

Heads you win, tails I lose! If a client using FC does not progress to independence this constitutes evidence that FC training does not work; if the client does become independent of facilitation this constitutes evidence that it was not necessary. This is not a standard normally applied to other areas of therapeutic intervention - to, say, aspirin. If you take an aspirin and your headache goes away the sequence of events is usually seen as evidence in favour of a connection between the pill and the relief. The relief certainly might be coincidence, but if anyone were to go further and claim that the fact that your headache had gone away demonstrated in itself that you could not have needed the aspirin in the first place the claim would surely be seen as bizarre.

Adams suggests that my writing ‘fuels the flames of incredulity’. I should be grateful, I suppose, that the burning of heretics is in our times no more than an emotional metaphor.

References
Biklen D, Saha N, Kliewer C (1995). How teachers confirm the authorship of Facilitated Communication: a portfolio approach. Journal of the American Association of Speech and Hearing 20, 45—56.
Biklen D, Cardinal D (1997). Contested Words, Contested Science.. New York: Teachers College Press.