A critical analysis of facilitated communication

The use of facilitated communication (FC) on Rom Houben, a 46-year old Belgian car crash victim, contributed to his recent diagnostic change from being in a persistent vegetative state to locked-in syndrome. In FC, a facilitator physically supports the hand of the patient, which is allegedly enough to allow the patient to communicate by typing letters on a keyboard. And while Houben’s case has thrust FC into the media, readers might be surprised to know that the principles behind FC are not new innovations at all.

In 1891, William Von Osten, a German schoolteacher, began publicly showing his allegedly brilliant horse, soon named “Clever Hans,” who could solve math problems by tapping his foot out to the correct answer. For years, scores of experts observed Clever Hans and attested to his mathematical prowess, until a German psychologist, Oskar Pfungst, undertook controlled studies of the horse in 1904. He concluded that the horse was certainly clever, but not for doing equations. Hans was paying attention to the subtle, involuntary cues that Osten — or an excited audience — emitted when the correct answer was given. The horse stomped his foot, and when the audience cheered, he stopped. Pfungst tested his theory by shielding Osten from sight, or by asking the questions to Clever Hans alone.

If this anecdote strikes you as outlandish, Google “Maggie the Dog” and you will see a more recent version. Maggie appeared on a number of popular shows over the past 10 years (including Oprah) with her trainer, who “discovered” her ability to do arithmetic spontaneously. In a talent show on Animal Planet, a flabbergasted judge exclaimed that she was looking for behavioural prompts by the owner, saying, “Now I’m floored, because usually when it comes to tricks like this, there are hand signals, [but] there is nothing!” However, the “magic” displayed by Maggie can be explained in the same way as Clever Hans: a clever animal picking up on its master’s cues.

So what does FC have to do with Clever Hans or Maggie the dog? They all involve the ideomotor effect — a phenomenon whereby someone subconsciously influences the subject. They aren’t necessarily aware that they are responsible for the action (whether it’s doing math, writing poems or communicating), and so they falsely attribute it to the subject. The problem is that people who work with the patients (families, facilitators, etc.) have traditionally been unwilling to entertain the idea that FC could be anything other than their loved one communicating. So, is it?
Professor Keith Stanovich from the University of Toronto documents the multitudes of controlled studies on FC in his book How to Think Straight about Psychology. He writes, “Each study unequivocally demonstrated the same thing: The [ . . . ] child’s performance depended on tactile cuing by the facilitator.” The studies generally involve showing both the child and the facilitator an object separately; the objects are sometimes the same and sometimes different. In such controlled studies, the children are able to type the object when the facilitator’s object matched their own (correct 100 per cent of the time), but not when they were different (correct zero per cent of the time).

Noted skeptic James Randi knows what it’s like to be frustrated with FC supporters. After being asked by Anne Donnellan of the University of Wisconsin-Madison to help investigate FC in 1992, Randi says that his studies “clearly showed that FC was simply a tragic farce.” Unfortunately, his results were completely ignored, perhaps because of his non-scientific background (or, as he says, because “the researchers were perhaps under the influence of the Clever Hans effect”). Michael Shermer, founding publisher of Skeptic Magazine, says that if the Houben case isn’t debunked soon, parents will be “setting themselves up for being crushed,” noting that they understandably want what’s best for their children. Unfortunately, he remarks, “FC doesn’t work.”

In 1993, PBS produced a documentary for Frontline called “Prisoners of Silence,” which exposed FC as a hoax. Every controlled trial demonstrated that the facilitator was the author of the messages. In fact, it showed that FC wasn’t just a “dead end” in research, but a detriment to its users. One of the facilitators, having been devastated by the results from controlled tests, immediately stopped using FC and told the school in which she worked to discontinue using FC altogether.

One of the more dramatic scenes in the documentary was footage of Rosemary Crossley (the inventor of FC) “communicating” with a boy who suffered a brain injury. A pointing stick attached to a helmet strapped to his head was used to point on a board that she was holding up. The boy was being asked to choose where he wants to live by moving the pointer to one of four labeled dots. The commentary indicates that the boy is in fact not pointing at all; by drawing an artificial line on the screen, it’s clear that Crossley is moving the board to make the dot line up with the stick. In case you’re wondering, the stick landed on “nursing home,” directly opposite from “parents.”

A lengthy research review in 1998 commissioned by the Department for Education and Employment (DEE) in the UK found that not only were studies showing that the facilitator was responsible for the messages, but that it would be difficult to even justify further research. Mark Mostert from Regent University also published an academic review in the Journal of Autism and Developmental Disorders in 2001, finding similar results to the DEE review. The American Psychological Association calls FC a “controversial and unproved communicative procedure with no scientifically demonstrated support for its efficacy.” In fact, five major U.S. professional organizations now formally oppose the use of facilitated communication, including the American Academy of Child and Adolescent Psychiatry, The American Speech-Language-Hearing Association, and the American Association on Developmental Disabilities. The Association for Behaviour Analysis International says that the use of FC is “unwarranted and unethical.”
Randi believes that FC was never a good idea. He says, “I cannot understand how anyone, professional medical person or layman, can continue to believe that [ . . . ] FC represents anything other than a fantasy.” It is doing more damage than good, and the Houben story may wreak havoc on the coma community. Final remarks from Prisoners of Silence seems to aptly apply to this case, even almost two decades after it was uttered: “As the evidence against FC accumulates, a painful question remains: whether parents or those who care deeply about [these] individuals are choosing to see them as they would like them to be, rather than respecting them for who they are.”