Note: John O'Brien and Connie Lyle O'Brien have written a number of articles and papers under a subcontract from the Center on Human Policy for the Research and Training Center on Community Living, under a cooperative agreement (Number H133B80048) between the National Institute on Disability and Rehabilitation Research and the University of Minnesota Institute on Community Integration. These are available through the Center on Human Policy (see end of article).

AGAINST PAIN AS A TOOL
IN PROFESSIONAL WORK
ON PEOPLE WITH SEVERE DISABILITIES

by John O'Brien, 1988
(Continued from Part 1)

Technically competent professional help (note 6) offers opportunities for meaningful activity, effectively teaches useful kills, directs and redirects attention, increases problem-solving abilities to make some difficult behavior unnecessary, helps people manage themselves more effectively, and shapes environments to decrease the incidence of hurt by defining and rearranging the pattern of consequences associated with someone including pain on self or others.

But technique will not eradicate suffering. Some people will strain the limits of technical competence with the inexplicable endurance or recurrence of violent or disgusting behavior. If we have the courage not to run from them and blame them for their disability, these people can teach all of us about building a social context in which we learn to decrease the occurrence of pain. This context is necessary for application of any technique to make sense and founds agreement against professional infliction of pain.

Each condition for limiting the occurrence of pain depends on all the others. (note 7) These conditions include: personal knowledge, mutual vulnerability, negotiated restraints on those who hold power over others, means to effect reconciliation, means to deal with the mystery of suffering, and widespread support to sustain relationships as people change over time.

Personal knowledge

Personal knowledge arises from concern for another's history, life situation, interests, and purposes. (note 8) It grows from spending time with someone in a variety of places and activities, from listening, and from seeking a person's interests and capacities. To build personal knowledge, approach people who inflict pain on themselves or others respectfully. Recognize that depersonalized environments breed pain and justify the professional use of pain (Guess et al., 1987). Account the costs of pain procedures on existing relationships with people who care for the person. Seek to understand what the person's violence communicates and what positive intentions it may serve given the context of their life situation. Enlist others who know the person in seeking understanding. Avoid explanations that blame the person who is inflicting pain on self or others. Search for capacities and interests that may be overshadowed by the person's violence.

Mutual vulnerability

Mutual vulnerability increases as physical and social distance decrease, as weaker people gain control over resources, and as purposes and projects are shared. It grows from a decision to allow the other to become important to us, to touch us personally. To build mutual vulnerability, stay close to people who inflict pain on themselves or others. Recognize that physical and social distance increases the likelihood of inflicting pain (Milgram, 1965). Challenge everyday practices that build distance between staff and the people who rely on them. Reject the notion that someone who examines data about a person and observes briefly can prescribe a solution to be implemented by others lower down the hierarchy. Invest in the people who live together with the violence to increase their effective control of their environment. Increase the control people with disabilities have over their circumstances, schedules, and helpers (Berkman & Meyer, 1988). Ally with people in discovering and pursuing meaningful projects.

Negotiated limits

Negotiated limits on what powerful people will do to weak people lie at the foundation of liberty. Because many people who inflict pain on themselves or others depend completely on environments designed and controlled by professionals, it is necessary to rule out pain as a therapeutic tool, but it is not sufficient to do so. Poverty, prejudice, isolation, ineffective help, and crowding too frequently shape the life conditions and opportunities of people with disabilities. To negotiate meaningful limits, begin by ruling out the use of pain as a professional too. Not because it might not work, but because it is wrong. Not because it is poor professional practice but because it is fundamentally opposed to constitutional guarantees of liberty. Realize that social norms that sanction people hurting others as a response to problem lie at the root of violence among people (Gelles & Straus, 1988). Acknowledge that the use of painful methods undermines the possibility of respectful human relationships (Kipnis, 1987; McGee et al., 1987). Recognize that bureaucratizing the administration of pain through due process multiplies the danger that inflict pain will become more impersonal and more extreme (Rubenstein, 1978). Clearly identify the social policies and professional practices shaping environments that breed pain and work systematically to change them.

Reconciliation

Reconciliation between people who have offended and hurt one another is essential to community life. Effective means for reconciliation combine agreement on and explanation of the hurtful event that strengthens common values; support for expression of hurt, indignation, anger and grief; agreement on restitution or penalty; forgiveness; and seeking a common project between parties to the hurt. Procedures that take the means of reconciliation away from the people involved and make conflicts into professional property hinder reconciliation even if they guarantee "due process" (Christie, 1977). Such impersonal processes work best when parties to a conflict can avoid one another after judgment is rendered; people who will continue to live together or share their daily life need to learn to heal their mutual hurts.

Suffering

Suffering is a human mystery that cannot be eradicated by the best technical effort or by our necessarily partial and incomplete efforts to build the conditions that limit the occurrence of pain. People who live with severe disabilities and those who assist them need to discover ways to come to terms with suffering. Dealing with suffering calls for recognition of the reality of suffering, finding meaning in its experience, and finding a way to continue life in the presence of suffering. Realize that compassion and caring are rooted in shared suffering.

Enduring positive relationships

Enduring positive relationships are the foundation for the mutual learning necessary to right live with people who inflict pain on themselves or others. To build enduring relationships, encourage personal commitments. Invest in people who want to make a commitment to one another and in the settings they share. Find reasons for relationships that go beyond technical help or personal assistance. Build circles of personal support that include some people with a bit of distance from everyday routines. Make time to reflect. Help people redefine their commitments as people and circumstances change. Celebrate people's fidelity to one another.

The more energy we put into producing therapeutic pain--and the more energy that has to go into fighting its use--the less energy is available for creating the conditions that limit the occurrence of pain. While the controversy goes on, people can create these conditions in small ways, close to people who inflict pain on themselves or others. And it is essential to do so. But the work will be easier the more widely it is shared.

I oppose the professional use of pain as a tool because it undermines each of the conditions for creating the community which decreases the occurrence of pain and sustains us to live together in our times of joy and in our times of suffering.

Note 6 - See, for example, Donnellan et al. (1988), LaVigna & Donnellan (1986), Evans & Meyer (1985), and McGee et al. (1987), for an array of techniques to deal with very difficult situations.

Note 7 - See Christie (1977; 1982), French (1985), Sarason (1974), and Vanier (1982) for other ways to describe these conditions and other ways to achieve them.

Note 8 - Although he does not use these terms, Lovett (1985) provides a helpful discussion of why and how to respond to people with challenging behaviors in ways that build personal knowledge and mutual vulnerability.

References

Berkman, K. A., & Meyer, L. H. (1988). Alternative strategies and multiple outcomes in the remediation of severe self-injury: Going "all out" nonaversively. Journal of The Association for Persons with Severe Handicaps, 13(2), 76-86.

Christie, N. (1977). Conflicts as property. British Journal of Criminology, 17, 1-19.

Christie, N. (1982). Limits to pain. Oxford: Martin Robertson.

Donnellan, A. M., LaVigna, G. W., Negri-Shoultz, N., & Fassbender, L. L. (1988). Progress without punishment: Effective approaches for Learners with behavior problems. New York: Teachers College Press.

DiIulio, J. J. (1987). Governing prisons: A comparative study of correctional management. New York: The Free Press.

Evans, I. M., & Meyer, L. H. (1985). An educative approach to behavior problems. Baltimore: Paul H. Brookes Publishing Co.

French, M. (1985). Beyond power: On women, men, and morals. New York: Summit Books.

Gelles, R. J., & Straus, M. A. (1988). Intimate violence. New York: Simon & Schuster.

Griffin, J. C., Palsey, T. J., Stark, M. T., & Emerson, J. H. (1988). B. F. Skinner's position on aversive treatment. American Journal on Mental Retardation, 93, 104-105.

Guess, D., Helmstetter, E., Turnbull, H. R., & Knowlton, S. (1987). Use of aversive procedures with persons who are severely disabled: An historical review and critical analysis. TASH Monograph Series, No. 2.

Kramer, H., & Sprenger, J. (1971). Malleus maleficarum. (M. Summers, Trans.). New York: Dover. (Original work published 1486).

Kipnis, D. (1987). Psychology and behavioral technology. American Psychologist, 42, 30-36.

LaVigna, G. W., & Donnellan, A. M. (1986). Alternatives to punishment: Solving behavior problems with non-aversive strategies. New York: Irvington.

Lovaas, O. I., & Favell, J. E. (1987). Protection for clients undergoing aversive/restrictive interventions. Education & Treatment of Children, 10, 311-235.

Lovett, H. (1985). Cognitive counseling and persons with special needs: Adapting behavioral approaches to the social context. New York: Praeger.

Mancuso, J. A. (1972). Caning: Educational rite and tradition. Syracuse: Syracuse University Press.

McGee, J. J., Menolascino, F. J., Hobbs, D. C., Menousek, P. E. (1987). Gentle teaching: A non-aversive approach to helping persons with mental retardation. New York: Human Sciences Press.

Milgram, S. (1974). Obedience to authority: An experimental view. New York: Harper & Row.

Rubenstein, R. J. (1978). The cunning of history: The Holocaust and the American future. New York: Harper Colophon.

Sarason, S. (1974). The psychological sense of community: Prospects for a community psychology. San Francisco: Jossey-Bass.

Skinner, B. F. (1984). A matter of consequences: Part three of an autobiography. New York: New York University Press.

Vanier, J. (1982). Community and growth. Toronto: Griffin House.

Wiseman, P. (in press). Deferring to the judgement of mental health and related professionals in striking the constitutional balance between individual liberty and the interests of the state. Columbia Human Rights Law Review.

For a list of articles and papers by John O'Brien and Connie Lyle O'Brien, please write to Rachael Zubal, Center on Human Policy, 200 Huntington Hall, Syracuse, NY 13244-2340 or call (315) 443-3851.

This article was prepared by the Research and Training Center on Community Integration, Center on Human Policy, Division of Special Education and Rehabilitation, School of Education, Syracuse University, with support from the U.S. Department of Education, Office of Special Education and Rehabilitative Services, National Institute on disability and Rehabilitation Research, through Cooperative Agreement No. H133B00003-90. No endorsement by the U.S. Department of Education of the opinions expressed should be inferred.

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