Position Statement on the Use of CESS
The following position statement was approved by the ABAI Executive Council in November 2022. After a two-week period of commentary by ABAI members, the ABAI Executive Council agreed to offer two position statements for a vote by the Full members, consistent with the ABAI bylaws. Both statements were informed by the CESS Task Force’s report and members’ commentary. Position A opposed the use of CESS except under extraordinary circumstances; Position B opposed the use of CESS under any condition. The two statements were put before the Full membership for a vote in fall 2022. At the end of the three-week voting period, 65% of voting Full members had voted to approve Position B (the statement below). As of November 2022, it is an official position of ABAI.
The Association for Behavior Analysis International (ABAI) and its members respect the personal dignity and worth of every human being and affirm each individual’s right to effective behavioral treatment and to freedom from inappropriate, unnecessary, and/or intrusive interventions. Behavior analytic principles constitute the foundation of the professional practice of applied behavior analysis and are essential to ethically sound and effective treatment programs. In accordance with these values, we strongly oppose the use of contingent electric skin shock (CESS) under any condition.
Our concerns center upon human rights, insufficient evidence demonstrating the efficacy of CESS compared to alternative treatments, a lack of social validity, and consistent cultural considerations being raised by individuals and organizations worldwide. Practices related to the use of CESS have the potential to harm individuals who receive it. The potential for harm is critical to consider when the procedure is applied to vulnerable populations and in a variety of cultural contexts, inside and outside of the United States. We are committed to promoting human rights, creating equitable and safe environments for all individuals, and respecting individual diversity and autonomy of all. As an international membership organization, this position statement is critical and necessary for upholding our commitment to sound ethical practice. This position and rationale are based on a careful review of the relevant evidence, ethical standards, and commentary received regarding the cultural implications, particularly for countries where CESS is illegal.
Limited Supporting Evidence
The science of applied behavior analysis has evolved sufficiently to where the current scientific literature base suggests that function-based interventions, as inspired by functional analysis methodology, are effective in treating severe challenging behaviors.
CESS can suppress behavior; however, as a treatment, it does not address the function of a behavior, and does not support the acquisition of prosocial or adaptive behavioral repertoires. In fact, the short- and long-term emotional side effects and likelihood of trauma produced by the procedure may interfere with the acquisition of such repertoires. The published literature based in applied behavior analysis does not support CESS as an evidence-based treatment. There is limited evidence that the treatment produces long-term maintenance of behavior change, promotes generalization of behavior change to naturalistic conditions, or enhances important quality of life outcomes during or after treatment. Moreover, there are limited studies published on CESS in behavior analytic journals, limited replication studies across multiple sites, and limited studies published by leading researchers with expertise in the assessment and treatment of challenging behavior. Finally, relatively few of those studies were methodologically rigorous or published after the year 2000, given that CESS is not a commonly accepted or socially valid practice. In short, behavior analysts must select interventions based on the current scientific literature.
Other concerning aspects with the implementation of CESS include the fact that its intensity must be increased in order for it to be effective, a technology has not yet been established for the effective withdrawal of treatment, the intervention may produce unwanted emotional side effects that jeopardize clients’ well-being, and contingencies may support misuse by staff. In addition, with a delay intervening between the occurrence of a behavior and the delivery of shock, it is likely that prosocial or adaptive behaviors may be punished.
Relevant Ethical Standards
There are many ethical issues germane to the use of CESS. A number of professional organizations have articulated such ethical concerns to the ABAI Executive Council and developed position statements regarding the use of CESS. Members of ABAI are bound to the code of ethics for their respective professional disciplines. Common ethical considerations include the following: Do no harm, minimize risks and maximize benefits, protect the welfare of clients, provide treatment within one’s scope of competence, obtain consent and assent for treatment, and implement practices that are based on scientific evidence. Based on these ethical considerations, it is the position of ABAI that CESS is an ethically questionable practice.
Cultural Implications
ABAI supports the growth of behavior science worldwide and commits to including international members. As an international organization, it is essential for ABAI to consider the impact of behavior analytic interventions for different cultures, both within the United States and internationally. ABAI as an organization bears the responsibility to represent international views and standards.
The field is evolving towards a compassionate application of behavior analysis, one that endorses humane and dignified practices. In addition to supporting effective and scientifically based interventions, ABAI must support interventions that are ethical, compassionate, and do no harm. Ensuring the protection of the most vulnerable, oppressed, and marginalized populations is paramount for behavior analysts. All practices should consider cultural variables (e.g., race, ethnicity, disability, nationality, gender identity/expression, sexual orientation, socioeconomic status), as well as potential privileges and power dynamics. Not considering these factors may contribute to inequitable or unethical interventions or practices.