The Implications of a Yes or No: Understanding Assent, Coercion, and Fair Choice in ABA Practice

Overview & Clinical Significance

The concept of assent in behavior analysis extends far beyond a simple yes or no. As Stephanie Bendush articulates in this course, assent is a human rights issue relevant to any practice where one person has power and influence over another. In the autism-ABA service provision model, this power dynamic is inherent and pervasive. The clinician controls the schedule, the activities, the reinforcers, and the physical environment. The client, often a child or an individual with limited communication, occupies a position of relative powerlessness. Under these conditions, the question of whether a person's yes truly reflects willing participation, and whether their no is truly heard and respected, has profound implications for clinical practice and human dignity.

The clinical significance of this topic lies in its universality across ABA contexts. Every session, every interaction, and every treatment decision involves an implicit or explicit question about the client's willingness to participate. When this question is ignored, when compliance is assumed or coerced, the therapeutic relationship is built on a foundation of control rather than collaboration. The consequences of this foundation extend beyond the immediate session: clients who learn that their preferences do not matter in therapy may generalize this learning to other relationships and settings, reducing their willingness to advocate for themselves in situations where self-advocacy could be protective.

Stephanie Bendush provides a nuanced examination of what constitutes a fair and reasonable choice. Not all choices offered to clients are genuine choices. A choice between two non-preferred options is not a meaningful choice. A choice offered under conditions where refusal is not truly an option is not a genuine choice. A choice presented without sufficient information for the person to make an informed decision is not a fair choice. Understanding these distinctions is essential for clinicians who want to move from nominal assent, where the form of choice-making exists without its substance, to genuine assent, where the client's participation reflects authentic willingness.

The course also addresses coercion in decision-making, a topic that is often overlooked in ABA training. Coercion can be overt, as when a clinician physically prompts a client to engage in an activity, or subtle, as when the reinforcement contingencies are arranged so that the only way to access preferred items or activities is to comply with clinician demands. Recognizing these coercive elements and redesigning practice to minimize them is a hallmark of ethical, person-centered ABA.

Background & Context

The background for this course includes the evolving understanding of assent within the broader context of human rights and disability law. The United Nations Convention on the Rights of Persons with Disabilities, adopted in 2006, establishes the right of persons with disabilities to make their own decisions and to have their choices respected. While the convention addresses legal capacity at a macro level, its principles translate directly into the clinical context: individuals receiving ABA services have the right to participate in decisions about their own treatment and to have their expressed preferences honored.

Within behavior analysis, the concept of assent has gained prominence as the field has engaged with criticisms from the autistic community about the power dynamics inherent in ABA practice. Autistic advocates have described experiences of having their preferences overridden, their communication ignored, and their compliance treated as the primary measure of treatment success. These accounts have prompted a reckoning within the profession about what it means to respect the autonomy of individuals who may not have the legal capacity to consent but who are nonetheless capable of communicating their preferences.

Stephanie Bendush's course addresses the specific parameters of assent, which is a contribution to a literature that has sometimes treated assent as an abstract principle without providing clinicians with concrete guidance on implementation. The course examines what constitutes a fair and reasonable choice, how coercion and skill levels influence decision-making, and the ethical implications of how practitioners respond when a client's assent is withdrawn.

The background also includes the recognition that assent exists on a continuum. At one end is enthusiastic participation, where the client approaches activities eagerly and engages with positive affect. At the other end is active refusal, where the client communicates clearly that they do not want to participate. In between lies a range of responses: passive compliance, which may or may not reflect genuine willingness; ambivalent engagement, where the client participates intermittently; and subtle avoidance, where the client uses indirect strategies to escape or delay activities. Clinicians must be attuned to this full range of responses to accurately assess assent.

The influence of coercion on decision-making is a particularly important background consideration. In ABA settings, the reinforcement contingencies are typically controlled by the clinician. When a client's access to preferred items, activities, or social interaction is contingent on compliance with clinician demands, the conditions for genuine choice-making are compromised. The client may say yes not because they want to participate but because refusal has historically resulted in the loss of valued reinforcers.

Clinical Implications

The clinical implications of understanding the parameters of assent affect how clinicians structure sessions, offer choices, respond to refusal, and evaluate the authenticity of their clients' participation.

The first implication involves how choices are offered. Many ABA programs include choice-making as a component of treatment, but the quality of those choices varies enormously. Offering a client the choice between two flashcard sets when neither is preferred and when refusing both is not an option is not meaningful choice-making. Genuine choice requires that the options are perceived as meaningfully different by the client, that at least one option is genuinely preferred, and that refusal is a viable alternative without negative consequences. Stephanie Bendush's framework helps clinicians evaluate whether the choices they offer meet these criteria.

The second implication involves recognizing and eliminating coercion. Coercion in ABA settings is often unintentional and embedded in standard practices. Token economies in which all reinforcers are accessed only through compliance create conditions where the client's participation may be motivated by the need to access basic preferred activities rather than by genuine willingness. Schedule-following practices in which breaks must be earned rather than available on request create conditions where the client has no easy exit from aversive activities. Clinicians who understand how coercion operates can redesign their practices to provide non-contingent access to some preferred items and activities, ensure that breaks are available without behavioral prerequisites, and create conditions where the client's yes is informative rather than coerced.

The third implication involves the relationship between skill level and decision-making capacity. Clients with limited communication repertoires may have difficulty expressing nuanced preferences. Clients with limited experience may have difficulty understanding the implications of their choices. These limitations do not negate the client's right to participate in decision-making, but they do place additional responsibilities on the clinician. The clinician must provide information in accessible formats, support the development of decision-making skills, and interpret behavioral indicators of preference carefully and conservatively.

The fourth implication involves planning for assent withdrawal. Stephanie Bendush emphasizes the importance of having a plan for what happens when a client withdraws assent. If the only plan is to continue the activity despite the client's refusal, the assent process is performative rather than genuine. Effective planning for assent withdrawal includes identifying the behavioral indicators of withdrawal, specifying the clinician's immediate response, having alternative activities available, and documenting the withdrawal and the response for review during supervision.

The fifth implication is for caregiver training. Caregivers need to understand why assent matters and how to support it in the home and community. When caregivers observe clinicians honoring their child's dissent, they may initially perceive this as the clinician not doing their job. Education about assent and its relationship to long-term outcomes helps caregivers become partners in assent-based practice.

Ethical Considerations

The ethical dimensions of assent, as Stephanie Bendush outlines them, are deeply connected to the power dynamics inherent in the ABA service provision model. The Ethics Code for Behavior Analysts provides the framework for navigating these dynamics ethically.

Code 2.11 (Obtaining Informed Consent) addresses both consent and assent. The code requires behavior analysts to attend to the assent of clients who cannot provide formal consent. This means that assent is not an optional add-on but a core ethical requirement. A clinician who does not actively monitor and respond to client assent is not meeting their ethical obligations, regardless of how well the intervention is designed or how positive the outcomes appear.

Code 1.08 (Avoiding Conflicts of Interest and Exploitation) is particularly relevant to Stephanie Bendush's discussion of coercion. When the reinforcement contingencies are arranged so that the client's only path to preferred outcomes is through compliance with clinician demands, a form of exploitation may be occurring, even if unintentionally. The client is being placed in a position where their participation is not truly voluntary because the alternatives to participation involve the loss of valued items or activities. Clinicians should critically examine their reinforcement systems to ensure that clients have access to basic preferred items and activities independent of their compliance with treatment demands.

Code 2.14 (Selecting, Designing, and Implementing Assessments) applies to the assessment of assent itself. Clinicians must develop valid and reliable methods for assessing their clients' willingness to participate. This requires individualized operational definitions of assent and dissent behaviors, systematic observation during sessions, and documentation that supports clinical decision-making.

Code 2.15 (Minimizing Risk of Behavior-Change Procedures) supports the principle that when a client consistently dissents from a particular procedure, the clinician should explore less aversive alternatives before continuing with the current approach. Persistent dissent is an indicator that the procedure's risks, as experienced by the client, may outweigh its benefits, and the clinician has an ethical obligation to respond to that indicator.

The course also raises ethical questions about the boundaries of assent. Not all dissent should result in immediate discontinuation of an activity. Safety-related tasks, medical necessities, and some adaptive living skills may need to continue even when the client prefers they did not. The ethical challenge is to distinguish between situations where overriding dissent is justified by clear and immediate benefit to the client and situations where overriding dissent is a convenience for the clinician or the system. This distinction requires careful clinical judgment and should be documented and reviewed during supervision.

Assessment & Decision-Making

Assessing the parameters of assent requires clinicians to evaluate not just whether a client says yes or no but whether the conditions surrounding that response make it a meaningful expression of preference.

The first assessment dimension is the quality of the choice being offered. Stephanie Bendush encourages clinicians to ask: Is this choice fair? Does the client have sufficient information to make an informed decision? Are the options genuinely different and at least one genuinely preferred? Is refusal a real option, or will it result in the loss of reinforcement, social disapproval, or the imposition of a less preferred activity? If the answer to any of these questions is no, the choice may not produce valid information about the client's actual preferences.

The second assessment dimension is the presence of coercion. Coercion can be assessed by examining the reinforcement contingencies surrounding the choice. If the client's access to preferred items, activities, or social interaction is contingent on choosing the option the clinician prefers, coercion is present. If the client has observed that refusal results in the removal of preferred conditions or the imposition of additional demands, the historical contingency creates a context in which the client's yes may be a product of coercion rather than genuine willingness.

The third assessment dimension is the client's skill level in relation to the decision being asked. Can the client discriminate between the options? Do they have the communication skills needed to express their preference? Do they have the experiential history needed to anticipate the consequences of their choice? When the answer to these questions is no, the clinician should provide additional support, such as allowing the client to sample both options before choosing, providing visual supports, or simplifying the choice.

The fourth assessment dimension is consistency of response. A client who consistently dissents from a particular activity across sessions, settings, and clinicians is communicating a genuine preference that should be taken seriously. A client who dissents from an activity on one occasion but engages willingly on others may be communicating a temporary state that can be addressed with environmental modifications.

Decision-making about assent should follow a structured process. When a client dissents, the clinician should first acknowledge the dissent, then assess the context, then determine whether the activity can be modified, postponed, or replaced, and then implement the decision and document the rationale. When a client assents, the clinician should not simply proceed but should monitor for signs that assent is maintained throughout the activity, recognizing that initial willingness does not guarantee continued willingness.

Planning for assent withdrawal should be proactive rather than reactive. Before beginning any activity, the clinician should have a plan for what will happen if the client indicates they want to stop. This plan should be individualized, documented, and communicated to the treatment team so that all clinicians respond consistently.

What This Means for Your Practice

Stephanie Bendush's course challenges behavior analysts to examine the power dynamics in their own practice and to take concrete steps to ensure that their clients' assent is genuine, informed, and respected.

Begin by auditing the choices you offer in your sessions. For each choice, ask yourself whether refusal is truly an option, whether the options are meaningfully different and at least one is genuinely preferred, and whether the client has the information and skills needed to make an informed decision. Where choices fall short of these criteria, redesign them.

Next, examine your reinforcement systems for coercive elements. Are all preferred items and activities gated behind compliance requirements? Can your clients access some preferred conditions non-contingently? Do your clients have a way to request a break or a change of activity that will be consistently honored? If not, restructure your contingencies to reduce coercion.

Then, develop and document assent withdrawal plans for each client. Before you begin any activity, know what you will do if the client says no, either verbally or through their behavior. Make sure your plan is genuine, meaning that it actually results in a change in conditions when the client dissents, not just a brief pause before resuming the same demand.

Finally, teach your clients to make choices and express preferences. These are among the most important skills you can teach, and they serve your clients across every context of their lives. A client who can say no and have that no respected is a client who is developing the self-advocacy skills that will protect them long after ABA services end.