Adithyan Rajaraman
TRIAD – The Autism Institute at Vanderbilt Kennedy Center
Department of Pediatrics, Vanderbilt University Medical Center
I struggled my whole life to have a consistent fitness routine. Despite my elementary school gym classes, lackluster attempts to be a middle-school athlete, collegiate notions that a better physique may attract a conspecific, and adult attempts to exercise because “fitness is important” and because “I want to look like Indian Thor,” I never achieved consistency with any moderate-to-vigorous physical activity. The stakes were not particularly low either; I was diagnosed with hypertension and hypercholesterolemia in my early twenties and every visit to the physician since then has centered around my weight and fitness. Discovering behavior analysis helped a little, because recognizing the role environments play helped me come to terms with the fact that my “will power” would not improve my fitness on its own and success in the gym was unlikely without environmental modification. As such, in my late twenties, I signed up for some group gym classes trusting that environmental contingencies may take over and evoke or induce better, more consistent performance.
CrossFit was popular at the time, so I trialed a few classes. Now, I do not wish to overgeneralize the CrossFit experience based upon the few classes I sampled, but they seemed to share a consistent training philosophy: You’re here to work. No excuses, no breaks, let’s go. The general strategy I perceived was that trainers attempted to push me to and beyond my physical limit by holding expectations in place (akin to an escape extinction procedure) and with the gentle threat of ridicule or shame for giving up (akin to punishing attempts to take a break or quit altogether). Of course, I independently chose to attend those gym classes, but once they started, I felt the sentiment was, “You’re not done until I say you’re done!” They tell you when you can stop—you don’t get to choose. As someone who chronically struggled to be motivated to keep at it in the gym, and as someone who needed a push, I did not find these classes to be effective or reinforcing. If anything, I was “push”ed away. Suffice to say I did not pursue membership.
It was not until recently that I found a gym environment that arranged the right contingencies to sufficiently reinforce my continued attendance. My primary care physician and I are overjoyed (and she is a bit relieved) to report I have been consistently attending the gym, multiple times each week, for the past two years. What do I think made a difference? I found a gym and a set of trainers who provided many ongoing options within exercises and who consistently reminded me that I do not need to over-exert myself unless I want to. The trainers at this gym regularly say things like, “You need not be here, but I am happy you are”; “You need not pick up that extra weight, but I believe you can”; “You need not complete that extra set, but I am here to support you if you choose to”; “You are free to stretch during this interval, but we are going to do burpees if you would like to join.”
It feels curious that the one fitness setting where I have been routinely offered an “out” is the one I have opted in to most consistently. Many of the other motivating factors were held constant across my lifelong health journey; I have known about my heart disease risk and have wanted to be and feel fit for decades. However, moderate-to-vigorous physical activity is very hard. It is a strange and unique operant class that somehumans do a lot even though it routinely produces aversive stimulation (e.g., pain, shortness of breath, fatigue) on a moment-to-moment basis. Nevertheless, the only context that seemed to reinforce my physical activity was one in which I was invited, supported, and encouraged to engage, but never required. I am certain my gym preferences are not universal, but I am equally certain they are not unique to me.
Choice has been studied extensively in basic and applied behavior analysis, both as an independent and dependent variable. There are now multiple empirical demonstrations, literature reviews, and practical guides that strongly support incorporating choices into applied behavior-analytic interventions. Furthermore, researchers in related disciplines such as animal training, trauma-informed care, and psychotherapy have made compelling arguments in favor of providing choices to those whose behavior we wish to influence. In fact, there may not be much new or novel to say about choice in the provision of applied behavior-analytic services, other than to continue advocating in its favor. Nevertheless, I would like to narrow in on the emerging observation, across personal experiences, clinical practice, and applied research, that sometimes simply giving the option to leave encourages individuals to choose to stay.
We are beginning to see a somewhat similar phenomenon in applied research on function-based interventions for dangerous behavior exhibited by children and adolescents, particularly when that behavior is in part motivated by escape or avoidance of certain adult expectations. Function-based interventions can be hard work for those experiencing them. They often involve repeated exposure to the very challenging situations that were previously evoking dangerous behavior, and careful teaching of alternative skills that individuals can use, in those challenging contexts, to produce similar reinforcers. For example, when a school-aged child exhibits aggression and property destruction when required to do schoolwork, a function-based intervention may endeavor to carefully and systematically teach the child to communicate their needs safely during distressing moments and cooperate with schoolwork requirements. It is not uncommon for the intervention to, at least initially, be met with resistance, protesting, and bursts of dangerous behavior.
In a handful of recently published studies evaluating an “enhanced choice model” of behavioral intervention, children were invited to participate in a function-based intervention while having concurrently available options to enter a “hangout” space with free access to reinforcers, or to leave the intervention environment altogether for the day. When implemented with children who were highly resistant to being told what to do, we found that in greater than 80% of the time in each published case, children chose to participate in intervention despite concurrent options to do much easier things. Children who had not successfully engaged with schoolwork for several years independently opted to put away their iPad and toys and sit at a table and be instructed by their teacher. Furthermore, those children virtually never engaged in any dangerous behavior while experiencing the intervention in which they chose to participate, something quite rare in the treatment of severe and dangerous behavior. Of course, there were many components of the intervention that likely contributed to positive outcomes, but importantly, having the overt options to disengage did not preclude—but rather may have facilitated—positive engagement. These children had the choice and explicitly chose to do hard things.
Dr. Pat Friman and his colleagues observed something similar in their evaluations of the bedtime pass program. Bedtime pass represents one among a handful of interventions, grounded in behavior-analytic principles, that successfully transcended mainstream pediatric care. The program, intended to address nighttime challenges associated with bedtime resistance (e.g., yelling out, leaving one’s bedroom), involves giving children a physical card (i.e., the bedtime pass) they can exchange for a brief, contextually appropriate visit outside their bedroom. Examples include exchanging a card for a glass of milk or a hug from a parent. Evaluations of the bedtime pass are unique in that they seldom involved rigorous analysis of the function of bedtime resistance and appeared to be aimed at providing an additional path to reinforcement while implementing extinction for bedtime resistance behavior. Bedtime pass often reduces or altogether eliminates nighttime challenges. However, an associated finding relevant to the current conversation is that, in many cases, children maintain low rates of nighttime challenges without needing to exchange their bedtime pass on each night. The option remains present, as children can still use their pass once each night, but simply having the option seems to be enough some of the time. The researchers postulated that the intervention potentially increased the children’s sense of control, thereby increasing efficacy and acceptance of the bedtime process. Yet another context in which giving children an “out” seemed to help them stay “in.”
This phenomenon seems peculiar, counter-intuitive, and yet, deeply human. Aversive stimulation is, by definition, something we tend to escape or avoid. Yet, in some unique situations, when that aversive stimulation is presented as an option (and is of course correlated with additional, possibly reinforcing outcomes), we approach instead. I suspect the strategy of providing the option to engage or disengage could help individuals meaningfully achieve their challenging goals beyond the gym, classroom, or bedtime contexts. That said, a useful next step will be understanding the necessary and sufficient conditions within an intervention environment that influence an individual to independently choose to do hard things. I assume that having basic needs met, being physically safe, and having a positive relationship with those tasked with helping us are important preconditions. I assume that some of the heat and aversion is mitigated from the environment when helping professionals convey, “You need not be here, but I am happy you are.”
Although some of the data to which I have referred are recent, and although a more formal behavior analysis of the relation between having the option and choosing to participate has not yet occurred, elements of this discussion are not at all new to behavior analysis. Israel Goldiamond advocated for arranging greater degrees of freedom in behavioral and therapeutic services, empowering recipients with multiple responses and opportunities to produce reinforcement. Researchers in Acceptance and Commitment Training (ACT) speak often about the critical importance of “willingness,” that recipients must volunteer to engage with therapy to have any hope of positive change. Basic and translational behavior-analytic research has repeatedly demonstrated that humans and nonhumans prefer having a choice between multiple response options over a single such option, even when either choice produces identical reinforcement. Having options matters.
Even Skinner touched on the topic by advocating for effective means by which to exert counter control on those who attempt to control our behavior. In his essay, “Compassion and Ethics in the Care of the Retardate,” published in Cumulative Record, Skinner discussed nuances of providing care for vulnerable, marginalized populations and importantly called for explicitly arranging opportunities for such individuals to easily and effectively protest or escape adverse conditions. I believe Skinner would agree it is extremely important that helping professionals who deal in behavior change acknowledge that our work involves controlling other people’s behavior. Perhaps what can be added to these meaningful and enduring contributions to behavior analysis is the emergent finding that providing these options is not only socially important and dignifying, but effective. In other words, having the option to do hard things (or not) may indeed help us choose to do those hard things.