Putting FC/S2C/RPM to the Test
The feedback we get from proponents about testing Facilitated Communication (FC) generally falls within these categories:
FC users say FC works and that’s “proof” enough.
Testing under blinded conditions is too stressful on the individuals being subjected to FC.
The existing tests that disprove FC are old and no longer valid.
Rapid Prompting Method (RPM) and Spelling to Communicate (S2C) are not FC and, circling back to (1), work because facilitators say they do.
Image by Them Masat
Let’s start with the last two.
The common denominator for all variants of FC is facilitator cuing. It matters much less what FC is called (e.g., S2C, RPM, supported typing, typing to communicate) than it does how the facilitator or assistant (consciously or not) interferes with the communication process.
Systematic reviews consistently demonstrate that there is no reliably controlled evidence that FC is an independent form of communication.
It is true many of the controlled tests for FC were conducted in the early to mid-1990s, but these tests clearly established facilitator control. By 1998, the following organizations had published statements opposing its use: American Academy of Pediatrics (AAP), American Academy of Child and Adolescent Psychiatry (AACAP), American Association of Mental Retardation (AAMR, now the American Association on Intellectual and Developmental Disabilities), American Psychological Association, American Speech-Language-Hearing Association (ASHA), and Behavior Analysis Association of Michigan (BAAM). Since then, other organizations have adopted opposition statements and/or published recommendations not to use FC.
Despite proponent claims that RPM is not FC, ASHA and AAIDD have statements opposing its use. The organizations cite similarities to FC, concerns about facilitator cuing, prompt dependency, potential harms, and lack of reliable evidence as the main reasons their opposition. ASHA categorizes S2C as a form of RPM.
A systematic review of RPM indicates no support for the technique, but also could not rule out its efficacy (largely because proponents refuse to test it). Instead of conducting scientifically rigorous studies to support their claims, as recommended by reviewers, proponents consider this review “empty.” Their approach appears to be to pretend that facilitator control over the typed messages is not a concern—even though facilitator cuing is clearly evident in pro-FC videos and movies—because, without access to participants in controlled settings, critics cannot definitively prove the extent to which facilitators are influencing the typed messages.
Proponents define “authorship” studies as the analysis of facilitated messages. It appears they are more interested in analyzing the linguistic structure of the facilitated, typed messages than they are in addressing facilitator cuing and control. Critics are concerned with who is controlling the messages during the typing sessions: the facilitator or the individual being subjected to FC. That has to be established before moving on to any analysis of the written output.
Image by Adam Wilson
A significant number of facilitators in the past were willing to participate in blind testing. Even though not testing is a guiding principle of FC, facilitators wanted to address doubts about their own influence over the typing activity. This led to the body of research available today and was a responsible action for facilitators to take. But, it seems, because the outcomes favored facilitator control over independent communication, proponents abandoned double-blind testing, presumably to preserve their belief in the technique. (See Review of A Passion to Believe). S2C and RPM users adopted this no-test approach from the start and, somewhat confusingly, appear to blame critics for the lack of current-day testing, even though it is up to proponents to prove their extraordinary claims.
Because cuing can be subtle and, in some cases, undetectable to the naked eye, blind testing is the only reliable way to rule in or rule out facilitator influence. By eliminating facilitators’ awareness of test protocols, researchers are better able to determine whether facilitated responses are 1) unintelligible, 2) based on what the participant knows, 3) based on what the facilitator knows, and/or 4) based on facilitator guesses (e.g., answers spelled correctly but unrelated to the information being explored during the testing).
The design of blind tests is critical. Tests with faulty structures fail to address the (measurable) problem of facilitator control. Carefully designed tests help rule out
Observer and experimenter expectancy (e.g., physical or verbal cues by the facilitator, guessing answers to a limited set of known content, or inadvertent sharing of information among facilitators and researchers)
Inadequate test procedures (e.g., practicing items, failing to obtain adequate baselines for independent vs. facilitated language and literacy skills)
Inappropriate test formats for the task (e.g., observations, facilitated interviews)
Cherry-picking data (e.g., reporting the “hits” or correct responses and ignoring the “misses” or incorrect responses)
To date, proponent testing falls into two major categories: studies with limited or no controls and studies which appear on proponent lists but are misleading in their depiction of FC as an evidence-based technique. Many proponent lists also include anecdotes and testimonials that may be a starting point for determining the legitimacy of FC as an independent form of communication, but do not provide reliably controlled evidence to back up the claims.
Image by Jason Goodman
Proponents claim blind tests are too stressful for their clients, though this seems to be negated by the fact that at least some individuals subjected to FC have graduated college, started businesses, produced movies, written books, and produced (false) claims of abuse against family members, care givers and educators. Surely these situations are more stressful than responding to a few simple questions they know the answers to, but the facilitators do not.
I found no documentation that client “stress” affected the results of any reliably controlled studies. On the contrary, facilitators and researchers reported that clients were cooperative. I expect this was because a) nothing significantly changes in the facilitator-client relationship during testing (except the facilitator is blinded to test protocols), and b) the researchers were experts in treating individuals with profound communication difficulties and sensitive to the needs of the participants. Commonalities among the tests included
Selecting the most successful facilitator/client pairs,
Using test protocols that included information the clients knew or should have known (e.g., familiar pictures, questions regarding the clients’ personal life),
Choosing familiar settings (e.g., school classrooms)
Allowing clients (e.g., those being facilitated) the option of stopping the test at any time, for any reason.
Concerns about client stress seemed to arise in FC literature after numerous tests failed to deliver the results the facilitators expected. It is likely these concerns reflected their own (facilitators’) anxiety about controlling the typed messages. In many cases, facilitators were devastated to learn the FCed messages were their words, and not those of their clients. (See Prisoners of Silence) Curiously, while evidence of facilitator control caused some to abandon the technique , it did not stop a percentage of facilitators from continuing the practice anyway.
As a former facilitator and someone who’s gone through double-blind testing, I understand facilitators’ reticence to participate. There is a lot at stake. While it is possible that a blind test will rule out facilitator cuing (hurrah if it does!), the weight of the evidence points to the likelihood that testing will rule facilitator cuing in. Facilitators considering testing should be aware of this possibility and prepare themselves to accept the results, whatever that may be. Facilitators, should also be aware that avoiding reliably controlled blind testing does not make the inherent flaw of the technique (e.g., facilitator cuing and control) magically resolve itself.
In a prior blog post, Katharine outlined some of the conditions necessary to conduct reliably controlled testing for authorship in FC/S2C/RPM. To these, I would add that:
Testing be contingent upon approval from an Institutional Review Board (IRB) or equivalent organization and meet ethical standards for human research. Members of the Board should be selected in accordance to mutually agreed upon guidelines (See FAQ About Institutional Review Boards). Set guidelines should be followed to ensure that appropriate permissions, test protocols, and safety issues be addressed.
The results be published in a reliable, peer-reviewed journal, regardless of whether the double-blind testing rules in or rules out facilitator control.
The facilitator and participant be provided support before, during, and after the testing to address any concerns that may arise as a result of participating in the test.
FC/S2C/RPM are techniques with a well-documented high degree of facilitator control that can be tested under reliably controlled conditions. I, personally, would love to see mandatory testing for all facilitators, especially since proponents refuse to accept the extant body of evidence against it. Saying FC works because people using FC say it works simply is not good enough.
I believe it takes a certain degree of courage and integrity for facilitators to follow through with double-blind testing and, further, accept the results even when it runs counter to their belief system or what they’ve been taught in training workshops. It is possible to believe in the client’s ability to independently communicate verbally and non-verbally using evidence-based methods and techniques while rejecting facilitator cuing and authorship in FC/S2C/RPM. The two are not mutually exclusive. Not only is double-blind testing scientifically responsible, it is, for those who are dead set on using FC, the only ethically sound course of action.
Please note: Individual contributors of this website are not prepared to conduct blind testing without appropriate supports in place (it takes a committee). However, if serious inquiries are made, we may be able to assist in developing an appropriate plan to move forward.