Facilitating communication (FC) was first introduced in the 1980s as a new method for helping non-speaking individuals to communicate. The basic method is for a facilitator to hold the hand of the non-speaker and help them point to letters on a board, or type at a keyboard. At first it seemed as if this was a breakthrough method, allowing many non- or minimally-speaking individuals to reveal their hidden inner voice. By the early 1990s, however, the illusion had burst. More and more studies began showing that the facilitator was the one doing all the communication, not the client.

Since then the professional community has largely been skeptical of FC. Appropriately burned by early acceptance of what is now clearly a pseudoscience, they have been extremely cautious of new methods since. Unfortunately, FC has never gone away. Like many pseudosciences, once banished from mainstream science because of things like high quality scientific evidence, it persists on the fringe, using a variety of dubious methods to fend off criticism and evidence. Many of these methods are common among alternative medicine pseudosciences in general.

Staking the moral high ground

This is perhaps the most pernicious method of pseudoscience promotion, because it attacks and stigmatizes professionals just trying to defend good science. With FC the narrative that has emerged is that those critical of FC are denying that any person who is non-speaking can have hidden cognitive abilities, that they are denying these people a voice and contributing to their marginalization in society, and that such a position is part of a broader “ableist” bias. Nothing could be further from the truth.

For example, the American Speech-Language-Hearing Association (ASHA) has a very clear position paper on FC in its various forms. They warn practitioners and clients that such methods are not scientifically valid and risk great harm. They can hardly be dismissed as not caring about those with speech challenges. They correctly point out that using an invalid method violates the rights of the person to their voice, by potentially substituting the voice of another (the alleged facilitator), that it distracts from other validated methods, and that there is no proven benefit.

Further, they correctly state that it is the responsibility of professionals to “first do no harm” which means only using methods that are validated and more likely than not to provide benefit rather than harm. The morality and ethics here are clearly on the side of those who are cautious about new methods with dubious features, but it is easy for proponents of FC to present themselves as the true champions of the non-speaking.

The American Association on Intellectual and Developmental Disabilities (AAIDD) also does not recommend FC or Rapid Prompting Method (RPM), which is a variation of FC.They cite the large volume of evidence that FC does not work and that the facilitator is the true author and the RPM lacks evidence and raises the same concerns of authorship as FC.

To be crystal clear, we all support the rights of the non-speaking completely. We want their true voices to be heard. We in no way minimize the abilities or intelligence of those who have either deficits of speaking or other ways of communicating. Also, it has to be recognized that autism is a broad spectrum, and no one can make blanket statements about what those with autism are able to do or not. Also, FC is not specifically about autism, but anyone who is non-speaking or minimally speaking.

Deceptive rebranding

Proponents of FC have done a good job of rebranding, confusing the public and some professionals in multiple ways. One way of rebranding is simply to use a different term, or to subtly change methods to appear different, when in fact the technique is essentially the same. Two such attempts at rebranding are the RPM and Spell to Communicate (S2C). With standard FC the facilitator holds the client’s wrist or hand. With RPM and S2C they hold a letter board in front of the client who then points without physical contact from the facilitator. These changes allow FC proponents to argue that the client is communicating on their own – but this misses the essence of what FC is.

ASHA refers to all of these methods with a properly descriptive term – “facilitator-dependent communication”. This is a good technical term which is operational, and therefore more scientific. The core question is this: is the communication in any way dependent on the facilitator themselves? The reason this is critical is because this opens the door for the facilitator to be influencing the communication, even to the point of being 100% responsible for the communication. And indeed, systematic reviews show there is no evidence that RPM is a valid method.

That was the primary lesson of FC and the science that demonstrated it was not a valid method. Facilitators were essentially deceiving themselves, partly through the ideomotor effect. This is the same process that allows a Ouija board to work, no one individual holding the planchette may be aware that they are pointing to the letters. It’s subconscious. But there is more – there are also components of the “Clever Hans Effect“, in which essentially random responses on the part of the client can be crafted into communication by the facilitator.

Videos are a good way to demonstrate these effects. I wrote previously about the case of Rom Houben, who is severely impaired due to an injury and is non-speaking. A practitioner of FC, however, claims that he can communicate fluently through the technique. As you can easily see through this video, however, these claims are patently false. Houben is barely looking at the keyboard, and while he does not have the ability to even hold up his hand, he is alleged to be typing rapidly and precisely through the facilitator. This is simply not possible, regardless of what is going on inside Houben’s consciousness. A neurologically intact individual could not cue the facilitator that rapidly and precisely. And of course, when tested with blinded information, it became clear that the facilitator was doing all the communication.

The lessons of this video and of all the research into FC over the last 30 years is that any method which allows for the inadvertent influence of the facilitator needs to be carefully studied in order to determine definitively who the author of the communication is. More simply (and as professionals such as the ASHA recommend) any facilitator-dependent methods should simply be avoided as too risky and not valid.

Hiding in the herd

With decades of negative research and persistent opposition by professionals and professional groups, how has FC hung on? Another method they have used is hiding in the herd, by which I mean proponents pretend as if FC is part of a broader category of legitimate communication methods, called Augmentative and Alternative Communication (AAC). AAC includes things like using pictures, letter boards, keyboards, or voice synthesizers. These are proven and helpful methods that are non-facilitator-dependent, and for which there is no question about authorship.

But if you say that FC is pseudoscience that does not work you may be accused of saying that AAC does not work, and that all non-speaking individuals have no ability to communicate. In fact, this exact thing happened in response to a recent SBM article about S2C. In the article Harriet Hall refers only to S2C, and never once mentions AAC or any accepted AAC method. And yet we received an angry e-mail stating:

In said article, Dr. Hall claimed that there is “little to no science” behind alternative communication for autistic people who do not speak…

He then provided links to articles backing AAC. The e-mailer (a medical student) will hopefully learn a valuable lesson in why science-based practitioners need to be precise. We cannot conflate FC with AAC, and we need to deconstruct diagnoses and interventions to their core features (again – facilitator-dependent communication). One of the articles he (and other e-mailers) linked to in order to “prove” that FC “works” is this one. It uses eye tracking to show that the clients in the study were the ones pointing at the letters, not the facilitators. Even if legitimate (and the study has been highly criticized), it has absolutely nothing to do with the question at hand, but does demonstrate another aspect of hiding in the herd.

The subjects in this study were all relatively high cognitive functioning individuals who had several years of experience successfully using a letter board. So it’s possible that communication that was not facilitator-dependent communication was going on in this study. But even that is contested, as the facilitator (who was not blinded) held and moved the board. This is being offered as evidence for facilitator-dependent methods – even by the authors of the study itself, who take a defensive tone throughout.

This demonstrates another deceptive method of promoting FC, including a large variety of activity under a broad umbrella. Every person with autism is different, and will have different strengths and weaknesses, and there are non-speaking individuals who have other issues and are not autistic. Further, different facilitators will use different methods, have different levels of training and experience, and a different understanding of what they are doing. A well-trained facilitator using a valid letter-board method that is not facilitator dependent on a client who is non-speaking but has significant cognitive function and is able to communicate cannot be generalized to all facilitators with all clients, just because they are using what is called AAC.

Proponents of FC also miss a major point with the scientific literature that calls FC into question. For example, they dismiss studies showing the facilitator is doing the communication because some individuals communicate differently and we cannot expect them to convey information like typical people would. That is a non-sequitur. They are missing the point that in these studies the facilitators were communicating. They were typing out what they thought the answers were. This damns facilitator-dependent methods regardless of the mental state of the clients.

The bottom line is – why wouldn’t facilitators use a fixed board? Why hold it at all? This just opens the door to facilitator contamination.

Conclusion: Facilitated Communication is still pseudoscience

Facilitated Communication is still pseudoscience, after three decades. We cannot let proponents push these harmful methods into mainstream methods for helping those who are non-speaking or have impaired communication. We can’t be confused by the shell game of shifting branding, and trying to pretend like it’s all ACC. Fortunately organizations like ASHA have figured all this out, but the proponents are tireless.

Author

  • Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.

Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.