Harmful Therapy Practices that Can Increase Risk of Sexual Abuse

By Maddie Fowler, Spark Doyle, and Gracee Wallach

Image description: A child with short curly hair wearing a blue shirt and jeans crosses their arms over their chest as seven different arms and hands reach from outside the frame and touch their body. A speech bubble above the child reads, “Hands to self.” The child has a scared, uncomfortable look on their face as the arms and hands are touching their hair and face, grabbing their arm, and lifting up their shirt.

Image by Ink and Daggers

Introduction

As societal ableism seeps into healthcare practices [1–6], many forms of “therapy” for disabled and neurodivergent people focus on compliance and conformity with the neurotypical world rather than on the wellbeing of the therapy recipients themselves [6–8]. One therapy often called out by Autistic individuals, professionals, caregivers, and allies for focusing on compliance rather than consent is Applied Behavior Analysis, or ABA [7–9]. In fact, the inventor of ABA, Ivaar Lovaas, was also the founder of gay conversion therapy, an abusive “treatment” that seeks to force LGBTQ+ people to appear cis and heterosexual [10]. The focus on compliance and conformity in therapies has led to multiple harmful practices that can cause mental health conditions such as PTSD, depression, and anxiety [8, 11]. In addition, these harmful practices can increase vulnerability to sexual assault [12]. The therapies teach recipients to adhere to everything a neurotypical person says without hesitation, and often include non-consensual manipulation of the individual’s body. [10] Autistic people face incredibly high rates of sexual abuse — 70% experience sexual assault by college age [13]. When seeking to empower disabled individuals through sexuality education, it is absolutely critical to address the sexual assault risk factors ingrained within the very therapies that are supposed to help disabled individuals.

While ABA therapy is often highlighted as the most problematic therapy for Autistic people, many forms of therapy for autistic and neurodivergent individuals include similar issues. The hidden abusive or grooming practices within such therapies are not always obvious as blasting a sound at a screaming child — they can include more subtle forms of demanding compliance, such as having a child repeat a motion and giving them candy for submitting. There are also many therapies that say they use ABA techniques, but do not actually employ the abusive practices that are foundational to ABA [14]. For this reason, it is important to be able to recognize the warning signs of harmful therapy practices within any therapy one might receive. This blog post compiles information from Autistic individuals and professionals to provide a list of red flags for dangerous practices in therapies that could increase the risk of sexual abuse.

Red Flags for Harmful Therapy Practices

🚩Observation not allowed

While caregivers sitting out of mental health counseling or psychiatric appointments is common and healthy in most situations, behavioral therapies (such as ABA) or rehabilitation therapy should always offer the option for caregivers to observe. If observation is prohibited, this could signal the use of abusive practices that the therapy provider does not want caregivers to discover [15].

🚩Punishment of any kind

Punishments could be as severe as restraint and seclusion, or more subtle such as refusal of a comfort object or stimming for a child in distress [15, 16].

🚩Lack of consent

Lack of consent in therapies can include touching the body without consent, but also prohibiting the child from saying no to therapy activities. Autonomy and self-determination must be respected in all healthy therapy practices [14].

Red flags might look like:

• “Hand-over-hand”: a therapy practice involving physically manipulating the autistic person’s body without their consent to force them to perform certain motions [17]
• Preventing the child from leaving an activity. Forcing a child to physically remain in the same position and doing the same activity without breaks or room for objection teaches children that their “no” does not matter.

🚩Focus on compliance and conformity

Focusing on compliance with therapists and parents, rather than cooperative work on applicable skills, teaches that autistic people have to do whatever neurotypicals or authority figures say and that their own form of self-expression is abnormal, inferior, and wrong [16, 18]. It puts them at higher risk of being taken advantage of by adults in their life who exploit their trust. This can lead to increased risk for sexual assault and other forms of violence and abuse. Additionally, this therapy practice prioritizes making autistics look and act like neurotypicals rather than helping recipients understand and advocate for their needs, and develop skills to accomplish their goals and function in daily life [16]. Therapy should prioritize the wellbeing of the recipient rather than the comfort of caregivers or neurotypical society [16]. Furthermore, when children are forced to feel shame and resistance around their own behaviors that they cannot control, it leads to compounding traumas which often exacerbate many of the behaviors these therapies try to prevent. [8, 19, 20]

Red flags might look like:

• Expectation to perform on demand [15]
• Child’s own method of play is discouraged or called “inappropriate” [14]
• Focus on external behaviors rather than functional skills [15, 16]
• Learned skills don’t transfer to real life situations and needs [15, 16]
• No stimming allowed [15, 16]
• Stimming is vital for self-regulation in many autistic people, and should never be interrupted unless causing harm to self or others. [21]
• Phrases such as “quiet hands”, or physically stopping recipient from stimming [14, 22]
• Requires eye contact
• Eye contact can be painful, and make it difficult to concentrate [14–16]
• Focus on verbal communication only [14, 15]
• Communication should be adaptive as many autistic people are able to express themselves more fully through sign language or electronic means.

🚩Ignoring needs and signs of distress

Refusing to acknowledge the basic and emotional needs of a person with autism teaches them that their own pain and feelings are irrelevant, and can lead to learned helplessness and shame [16, 18]. This could reduce an individual’s ability to recognize that any abuse they experience is unacceptable. This practice can also lead to ignoring critical symptoms of mental health conditions, potentially worsening their effects. [8, 19, 20]

Red flags might look like:

• “Extinction:” intentionally ignoring signals of distress in the hopes that the recipient will stop performing a certain behavior [14, 23]
• The term “extinction burst” used to describe emotional reactions to being forced into overwhelming activities [14]. “Extinction burst” refers to a child increasing signs of distress [24] as a cry for help when their needs/pain are being ignored.
• Failure to listen to person’s pleas to stop when overwhelmed [14]
• No understanding of the need for sensory breaks [14]
• Meltdowns treated as tantrums [14]
• Autistic meltdowns are a response to overload and distress and their root cause must be recognized and addressed to resolve the situation [16]. Meltdowns are not on purpose, not controllable, and often leave the child scared and upset. They are caused by the brain becoming so overloaded that it starts over-firing.
• Describe distressed behavior as “attention-seeking” rather than seeking its root cause [14]

🚩Reliance on repetitive, external reward based training

Therapies based on repeated discrete trials with food or other external rewards as motivators are dehumanizing, ineffective, and use many of the same practices as dog training [25–33]. They avoid addressing the root cause of the behavior or teaching the importance behind each skill learned, instead focusing on compliance without question. Additionally, external rewards can reduce intrinsic motivation and cause prompt- and reward-dependence [25–33].

Red flags might look like:

• Excessive reliance on token systems that bribe the recipient into compliance [14–16]

🚩Therapists performing tasks they are not trained for

Professionals working with autistic people should never perform tasks outside of their explicit training. For instance, ABA registered behavior technicians (RBTs) are only required to complete 40 hours of training to become certified and do not need a college degree [34]. Performing some therapies without proper training can be dangerous or even life threatening if not performed correctly [8, 35].

Red flags might look like:

• ABA therapist performing feeding or mobility therapies without training [35]
• ABA therapist performing treatment for serious mental illness [8]

🚩Exposure therapy for sensory sensitivities

Exposure therapy, or repeated, increasingly prolonged exposure to the cause of distress, is meant for conditions such as phobias or PTSD, not for sensory sensitivity [36]. Sensory sensitivity in autism does not come from fear or illogical beliefs, but from differences in neural wiring and screening of environmental stimuli [37]. Thus, exposure to painful stimuli in sensory sensitivity does not make the stimulus less painful, but teaches individuals to expect to be hurt, and trust those who hurt them.

Red flags might look like:

• Therapists believing that sensory needs should be overcome rather than respected [14]
• Prioritizing achieving results rather than preventing sensory overload [14]

🚩Extreme time commitment

Children should not be expected to perform the work of a full-time job, yet this is what many therapies recommend. This overload of hours alone can be harmful to therapy recipients by preventing the recipient from having breaks from therapy, and taking control over the majority of their life. This complete immersion into therapy is exhausting and painful and can contribute to burnout. [15, 38–40]

Red flags might look like:

• Extreme weekly hours
• For example, some ABA professionals recommend up to 40 hours a week of therapy (can even be on top of time in school) [15]
• Indefinite therapy
• All therapy should have an end goal and projected stop date, rather than seemingly endless duration without concrete parameters and metrics [15]

🚩Rigid approach, refusal to make accommodations

Therapies should be manageable for recipients and take into account any modifications that should be made to enable accessible engagement with learning [15].

Red flags might look like:

• Therapists push the recipient to play “their way” without regard for abilities and challenges [14]
• Moving too fast or not breaking down tasks [15]

🚩Presumes incompetence

All recipients should be treated as competent and be consulted in the formation of goals and activities for their own therapy [15, 16].

Red flags might look like:

• Words like “dysfunctional” or “non-functional” used to describe the recipient [15]
• Making decisions for the recipient rather than seeking their input [16]
• Not listening to the recipient’s input, or thinking therapist knows better than recipient about recipient’s lived experience, wants, and needs

Some First Steps to Take if You or Your Loved One is in Abusive Therapy

1. Listen to the affected autistic person’s needs. Make sure that you find/provide a safe space where expression of emotions is welcome and autonomy is respected, and decisions are guided by the affected person.
2. Stop the therapy immediately. Determine if a report to authorities is needed.
3. Connect the individual to people they can trust to talk about and address their experiences, outside of their family or ABA therapists.
4. Seek mental health screenings for PTSD, anxiety, depression, eating disorders, insomnia, and other mental health conditions that are relevant for experiences of long term trauma/abuse. Seek out mental health counseling if the affected person is willing.
5. Provide comprehensive, trauma-informed sexual education that emphasizes consent, bodily autonomy, self esteem, freedom of choices, affirmation of gender and sexuality.
6. Help the individual learn how to say “no” to authority figures including therapists. If you are the individual’s caregiver ask them to let you know whenever they have said “no” to an authority figure and/or experienced something that made them feel uncomfortable or unsafe.

For more ABA-specific resources and info, please view our resource list: https://docs.google.com/document/d/1Mb_630FCEV6SWVLLsaP9YvZRGvwf1Ey_iEzATzNxOU8/edit

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