Behavior Analysis in Practice

https://doi.org/10.1007/s40617-023-00890-1

SI: COMPASSION IN APPLIED BEHAVIOR ANALYSIS

Foundations of Preemptive Compassion: A Behavioral Concept

Analysis of Compulsion, Consent, and Assent
Anna M. Linnehan1 · Awab Abdel‑Jalil1,2,3 · Sheila Klick1,4 · Jonathan Amey5 · Richele Yeich2,3,6 · Kyle Hetzel7

Accepted: 7 November 2023

© Association for Behavior Analysis International 2023

Abstract
The recent changes to the Behavior Analysis Certification Board Ethics Code for Behavior Analysts along with the calls to
action for compassionate care have highlighted the need for a reevaluation of behavior research and clinical programs. We
propose a behavior analytic definition of compassion where the relieving or prevention of distress is the reinforcer for the
professional. One way of minimizing distress may be to require that assent be provided by a participant in an intervention.
The definition of assent typically includes reference to willingness to participate in an intervention or activity. We provide
a framework that goes beyond simple willingness to participate and distinguishes between apparent/implicit coercion and
genuine assent by considering the alternatives described as degrees of freedom available to the participant. We distinguish
between compulsion/explicit coercion, consent, and assent. Additionally, we will differentiate genuine consent and assent
from apparent consent and assent in the design of compassionate behavioral programs.

Keywords Compassion · Compulsion · Consent · Assent · Degrees of freedom

The relation between how we talk about events, and problems which might otherwise not have been pur-
what we otherwise do about them, is, of course, of sued. (Goldiamond, 1975, p. 49)
interest not only to students of philosophy but also to
Given as Goldiamond noted, the way we talk about
students of behavior analysis. The terms we use tend
events influences what we do about them—the procedures,
to classify our observations. They may thereby dictate
we propose a nonlinear contingency analytic (Goldiamond,
what it is that we admit as data, and govern our data
1984; Layng et al., 2022) definition of, and approach to
collecting procedures. In a scientific discipline, ter-
assent. This is not only to ensure a common language and
minological problems can lead to the formulation of
understanding of assent but also to encourage behavior
scientific puzzles and to the pursuit of experimental
analysts to use least restrictive, noncoercive procedures in
the moment-to-moment treatment of their clients. In this
issue, Abdel-Jalil et al. (2023) describe in detail the rela-
The authors are indebted to Dr. T. V. Joe Layng for all his help,
tion between a nonlinear contingency analysis of assent
guidance, feedback, and mentoring during the conception and and compassion. We will extend this nonlinear treatment
writing of this article. of assent by providing a behavioral concept analysis impor-
tant to achieving compassionate outcomes, and distinguish
* Anna M. Linnehan
[email protected]
between compulsion, consent, and assent when used in
behavioral programs. Further, we will make the distinction
1
Endicott College, Institute for Applied Behavioral Science, between apparent consent and assent (implicit coercion) and
Beverly, MA, USA genuine consent and assent.
2
Eastern Florida Autism Center, Palm Bay, FL, USA Taylor et al. (2019) state “. . . compassion converts empa-
3
Great Leaps Academy, Palm Bay, FL, USA thy into an act aimed at the alleviation of suffering” (p. 655;
4 emphasis added). We maintain this distinction between
Melmark, Berwyn, PA, USA
5
empathy and compassion with some added clarity. Empathy
AIMS Instruction, Pittsburgh, PA, USA
is defined as behavior that expresses concern over another’s
6
University of West Florida, Pensacola, FL, USA distress, but does not necessarily involve actions taken to
7
Oakland Zoo, Oakland, CA, USA relieve that distress. Compassion is defined as behavior

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 Behavior Analysis in Practice

maintained by (aimed at—à la Taylor et al.) the removal or Degrees of Freedom

mitigation of distress in others. We contend that preventing
distress is also compassionate (cf. Scallan & Rosales-Ruiz, Writing for the National Commission for the Protection of
2023). In describing his constructional approach, which Human Subjects of Biomedical and Behavioral Research,
emphasizes the establishment rather than the elimination Israel Goldiamond made the distinction between apparent
of behavior, Goldiamond (1974/2002, p. 180) pointed out consent (implicit coercion) and genuine consent (Goldia-
that constructional programs can prevent distress by seeking mond, 1976). To accomplish this Goldiamond employed a
“constructional solutions which alleviate human distress by nonlinear contingency analysis that requires that the conse-
preempting it” (p. 184; emphasis added). Thus, we define quences maintaining the behavior, signing a consent form
compassion as behavior maintained by the removal, mitiga- in this case, be evaluated in the context of the available
tion, or prevention of distress for others. In the case of the alternative contingencies that provide the same critical con-
latter, we maintain that procedures that often result in refusal sequence. It is important to emphasize that having other
and uncooperative behavior can be replaced by procedures available contingencies is not enough, they must provide
which maintain involvement without aversive interventions, the same critical consequence. Goldiamond described this
behavior decelerating practices, or restrictive positive rein- further through two related formulas: degrees of freedom
forcement procedures. and degrees of coercion. Degrees of freedom (df) are cal-
In clinical practice and research, behavior analysts are culated by considering the number of contingency alterna-
required to follow ethical guidelines set forth by their cre- tives (n) within a given context and subtracting by one,
dentialing board, the Behavior Analysis Certification Board resulting in the following formula: df = n -1. For exam-
(BACB), to protect the consumer as well as the certificants. ple, if one is offered a surgical procedure or alternatively a
The Ethics Code for Behavior Analysts defines assent as series of medications to repair a damaged heart, the patient
“vocal or nonvocal verbal behavior that can be taken to has one degree of freedom (2 - 1 = 1). If a regimen of
indicate willingness to participate in research or behavio- diet and exercise over time can also result in repair, the
ral services by individuals who cannot provide informed patient has two degrees of freedom (3 - 1 = 2). Consent
consent (e.g., because of age or intellectual impairments). then is not solely governed by the ultimate consequence of
Assent may be required by a research review committee or a repaired heart, but also by other program-specific (after
service organizations, in such instances, those entities will Goldiamond, 1974/2002; 1976) consequences. In this case,
provide parameters for assessing assent” (BACB, 2020, p. such program-specific consequences might include time
7). In addition to guidance provided by the BACB, behavior to repair, recovery time, monetary costs, response effort,
analysts conducting research in the United States must also effects on the family, and so on. Genuine consent, there-
adhere to federal regulations set forth by the U.S. Depart- fore, requires a minimum of one degree of freedom.
ment of Health and Human Services in the protections of It is important to note that the option to obtain the same
human subjects in research (Federal Policy for the Protec- consequence is not the defining feature, it is the option to
tion of Human Subjects, 2018). Regulation §46.402 defines obtain the same critical consequence, that is, given a vari-
assent as “. . . a child's affirmative agreement to partici- ety of consequences, it is the one that governs the contin-
pate in research. Mere failure to object should not, absent gency (Goldiamond, 1976; Layng, 2020). Thus, where two
affirmative agreement, be construed as assent” (Federal options are given that produce the same consequence and
Policy for the Protection of Human Subjects, 2018, Subpart not choosing one of those two results in an aversive event,
D). In addition, federal regulations provide guidance for without which neither would be chosen, it is the aversive
institutional review boards (IRB) in determining if assent is event that is the governing contingency, and thus degrees
required for children in research and under what conditions of freedom are not defined.
assent may not be required. As described, degrees of freedom can be measured by
Whereas the BACB and the U.S. Department of Health identifying the alternative contingencies available that
and Human Services do not provide an analytical tool to provide access to a critical consequence (de Fernandes
evaluate assent, they do share language in the “willingness” & Dittrich, 2018; Goldiamond, 1976; Layng, 2020).
or “affirmative agreement” to participate. Possible topo- Although an occasion • behavior relation may have many
graphic indicators might include, approaching an activity, consequences, as noted in the heart damage repair example
e.g., walking, turning, reaching, and possibly affect, such as above, the consequence that governs the contingency, a
smiling, or a spoken “yes.” But is willingness or affirmative repaired heart, is the critical consequence (Goldiamond,
agreement to participate, regardless of the indicator, really 1976; Layng, 2020). Stated otherwise, it is the reinforcer
the indicator of genuine assent? The next section addresses for engagement in the activity. Of course, for a contingency
this question. to be available all of its elements must also be available: the
Behavior Analysis in Practice

occasion, behavior, and consequence (Layng et al., 2022). concept (Bruner et al., 1956; Engelmann & Carnine, 1982;
Removing an occasion, even if the behavior is otherwise Layng, 2019; Markle & Tiemann, 1969; Mechner, 1962;
available also eliminates the critical consequence, e.g., the Merrill et al., 1992; Nishimuta & Layng, 2021; Sota et al.,
heart medications are unavailable. Likewise, removing the 2011; Tiemann & Markle, 1991). The concept analyses (cf.
behavior, e.g., an old injury prevents vigorous exercise, abstract tact; Skinner, 1957) offered here are based on an
can also eliminate an alternative. When surgery is the last analysis of the available alternative contingencies before,
remaining option, no degrees of freedom exist. The patient during, and after deployment of a program/treatment. Fur-
is coerced into surgery and may willingly sign the consent ther, the concept analyses of the coordinate concepts (see
form. The program intrinsic consequences of monetary Layng, 2019) compulsion, consent, and assent, are used to
cost, recovery time, and so forth do not have their effect if delineate between genuine consent and assent, as opposed
one is to survive. Where there is only one way to achieve to apparent consent and assent (implicit coercion).
the critical consequence, genuine consent is not possible
and the consent may be considered fully coerced; one must
consent to the surgery or die if no other alternatives are Critical/Must‑Have Features
offered. The critical consequence need not be a positive
reinforcer as in the case where either a general and or local As seen in Fig. 1, the coordinate concepts compulsion,
anesthetic is offered so we can avoid a painful experience. consent, and assent and their corresponding critical/
Hence there are two negative reinforcement contingencies must have features are described. Compulsion, consent,
where the local and general anesthetics can have their pro- and assent share one crucial feature, program participa-
gram intrinsic effects. tion. That is, there is a discernible topographical behavior
We maintain that assent can similarly be treated. This indicating a tendency to participate in the program. Each
approach provides a preliminary framework for preventing concept varies in how the contingencies are arranged for
a state of distress/suffering by preemptively programming to participation.
maximize degrees of freedom. By doing so, we create the In compulsion, the critical/must have features are (1)
least coercive possible environment, thereby ensuring that program participation; (2) by any organism; (3) where
learner assent reflects at least one degree of freedom. It is refusal to participate or an attempt to withdraw from par-
important to note that the presence of at least one or more ticipation leads to an aversive event. The aversive event
degrees of freedom does not imply the complete absence of may be physically forced movement, or an aversive conse-
cost for the organism. What it does is to allow this difference quence for noncompliance—can have features. Although
in cost to affect the behavior of the organism (see below). positive reinforcement may be provided as part of the
program, program compliance is maintained by the aver-
sive events for noncompliance. Willingness to participate,
Compulsion, Consent, and Assent: therefore, is not a consideration. Where physical guidance
A Behavioral Concept Analysis is resisted or avoided, such forced compliance is consid-
ered compulsion. Under those conditions where guidance
We describe and distinguish between three forms of pro- provides program intrinsic reinforcers (see below) it does
gram participation: compulsion, consent, and assent. Fur- not necessarily fall under the category of compulsion.
ther we offer definitions of each based upon a concept Consent requires (1) program participation; (2) where
analysis (after Layng, 2019; Tiemann & Markle, 1991) that affirmative agreement to participate is obtained from a
describes the critical features found in each concept and person who meets criteria for legal ability to agree (con-
some of the varying features found in the concept of assent. tract); and (3) occurs prior to implementing the proce-
“A concept is a class or category all the members of which dures. When a different set of procedures is required, addi-
share a particular combination of critical properties not tional consent is also required (see Goldiamond, 1976,
shared by another class” (Markle & Tiemann, 1970; also for an extended discussion of informed consent and its
see Layng, 2019). All members of the class or category implications).
that comprise a concept, share properties that, if absent, Assent requires (1) program participation; (2) by any
produce a nonexample of the concept (Tiemann & Mar- organism; and (3) where agreement to participate is obtained
kle, 1991). These properties or features are “must have” continuously during the program. Further, assent may be
features (Layng, 2019). That is, each example of the con- provided by both verbal or nonverbal participants, including
cept must have certain features that define the concept. If nonhuman participants, such as zoo animals (see Abdel-Jalil
a must have feature is absent, a nonexample of the concept et al., 2023). It requires no legal standing and occurs once
is produced. In addition to must have features, concepts legally defined consent is obtained from a source legally
can also contain “can have” features which vary within the able to provide it.
 Behavior Analysis in Practice

Fig. 1  Participation in a
program behavioral concept
analysis Participation in an Activity or Program

Compulsion/Explicit Coercion Consent Assent

1. Program participation 1. Program participation 1. Program participation

2. Any organism 2. Person able to legally contract 2. Any organism
3. Application of aversive 3. Discrete event, prior to 3. Agreement to participate is
for non-participation implementation of program obtained continuously during
the program

Apparent/ Apparent/
Genuine Genuine
Implicit Coercion Implicit Coercion

4. 0 degrees of 4. ≥1 degree of 4. 0 degrees of 4. ≥1 degree of

freedom to freedom to freedom to freedom to
achieve critical achieve critical achieve critical achieve
consequence consequence consequence critical
consequence

Distinguishing Genuine Assent from Apparent consent and assent are considered fully coerced. That is, there
Assent (Implicit Coercion) is but one way to obtain a withheld critical consequence, even
if that consequence is a positive reinforcer. Institutions (or indi-
As described earlier, an additional critical/must have feature, viduals) can arrange the conditions that make a critical conse-
degrees of freedom, distinguishes apparent/implicit coercion quence contingent on a single way to obtain it, institutionally
from genuine consent. Likewise, degrees of freedom can be instigated coercion, or may take advantage of environmental
used to distinguish apparent/implicit coercion from genuine conditions, institutional opportune coercion, that do so (see de
assent. Assent may also be considered coerced if an indi- Fernandes & Dietrich, 2018; Goldiamond, 1976).
vidual has only one path to achieve the critical consequence, It is important to note that even when a degree of free-
yielding zero degrees of freedom. Apparent/implicit coer- dom exists, one alternative may simply provide the lesser
cion assent is defined when an individual “willingly” partici- of two evils in terms of the costs to the individual. This at
pates in an activity, but does so because there is no other way least provides a means of reducing the aversiveness of an
to obtain a critical consequence. “Genuine” assent occurs activity and perhaps more important, allows a practitioner
when there is at least one degree of freedom in obtaining to have a way of comparing procedures. By continually
the critical consequence. That is, activity A or B both result offering different alternatives, one can ascertain which pro-
in the same critical consequence. Now, other consequences cedures result in the greatest reduction of aversiveness and
that may directly arise from the activity can have their effect. the greater likelihood of program intrinsic reinforcement,
Thus, genuine assent requires at least one degree of freedom, resulting in more compassionate programming.
and is distinguished from apparent/implicit coercion assent Figure 2 provides a brief, abridged concept analysis of
where participation is maintained through its sole access to genuine assent that depicts both the critical/must have fea-
the critical consequence, zero degrees of freedom. tures and some of the variable/can have features of the con-
Figure 1 describes the critical/must have features of each cept. Although there is a wide range of variable/can have
concept and how the addition of degrees of freedom distin- features, for the purpose of this discussion three categories
guishes between apparent/implicit coercion and genuine assent. were selected, approach responses, individual arranging
With zero degrees of freedom apparent/implicit coercion the contingencies, and assenting participant. These were
Behavior Analysis in Practice

Fig. 2  Genuine Assent

Abridged Concept Analysis

selected to illustrate the role of varying features as they may can be gained within behavioral practice for both verbal
be commonly occurring for practitioners. and nonverbal participants.
Approach behaviors refer to a specific response class Some example (EG) and nonexample (NEG) vignettes
that involves active engagement within the instructional are provided to illustrate the distinction between apparent/
or research context. Some examples may include talking, implicit coercion and genuine assent.
writing, reading, moving toward, or spending currency
(tokens) on an object or event (Mager, 1997). The second 1. EG: Davonte is a picky eater. During his food expansion
variable feature is the individual arranging contingencies. program, Davonte is presented with three non-preferred
Assent within behavioral programs can be considered a foods on a plate. Davonte can obtain his favorite cookie by
relation between an individual arranging contingencies interacting with the non-preferred food in any way (touch,
(e.g. BCBA, caregiver, RBT, animal trainer), and the smell, lick, bite, etc.), or at any time walk to another table
“assenting” participant(s) (e.g., learner). across the room to gain access to his favorite cookie.
We argue the addition of apparent/implicit coercion and 2. NEG: Elenore is a picky eater. During her food expan-
genuine, which require an analysis of degrees of freedom, sion program, a bite of the nonpreferred food is held up
represent a more thoroughgoing analysis that is essential to her mouth. She must open her mouth and accept the
to determine the level of coercion in programs/treatment. bite for the spoon to be removed. Opening her mouth and
In this approach, coercion is defined not simply through accepting the bite is the only way the spoon is removed.
application of force or aversive stimuli, but also through (Compulsion/explicit coercion, zero degrees of freedom)
positive reinforcement when there is only one way to 3. EG: An RBT notices Melinda glancing at the cookie
obtain a critical reinforcer. Thus, many common practices jar on the shelf. The RBT said “What do you want?”
such as differential reinforcement of alternative behavior Melinda can get a cookie by any of these skills
(DRA), differential reinforcement of incompatible behav- which are currently in her repertoire, verbally saying
ior (DRI), and differential reinforcement of other behavior “cookie,” signing, or exchanging a picture with any of
(DRO) often may be categorized as coercive along with the staff in the classroom. (The topography Melinda
escape extinction and forced correction. Current BACB chooses allows the RBT to evaluate the consequences
guidelines stipulate that if one is required to choose which other than cookies that maintain saying, signing, or
procedure to use, an aversive event or reinforcer, current exchanging a picture.)
practice dictates using positive reinforcement (Ethics Code 4. NEG: Xavier was reaching for a snack. The RBT
for Behavior Analysts, section 2.14). However, either pro- pointed to the snack, and said “What do you want?
cedure can be coercive and both have by-products which Snack?” The only way Xavier can get the snack is
must be considered. Abdel-Jalil et al. (2023) provide a by saying the word “snack.” (Implicit coercion, zero
range of case studies demonstrating how genuine assent degrees of freedom)
 Behavior Analysis in Practice

5. EG: Lucas’s highly preferred activity (critical conse- chooses one path over another, it can inform us as to how
quence) is playing with peers. The RBT offers Lucas our programs need to be changed so the program itself will
a few choices of programs which all involve play with produce more activity specific reinforcers than an alternative
peers: (1) a matching game program; (2) a tacting pro- (for applied examples, see Abdel-Jalil et al., 2023).
gram, e.g. “I spy . . .”; (3) an imitation program. At times, compulsion may be justified given certain
6. NEG: Charlie’s highly preferred activity is playing contextual factors, such as legal, safety, medical, etc. In
with peers. The RBT offers Charlie a few choices of short, degrees of freedom may be a useful starting point
programs to do: (1) a matching game program, and for considering the amount of genuine choice embedded
earn play time with peers; (2) he can do a tacting within the treatment or research context. However, further
program, and earn candy; (3) he can do an imitation analysis is advocated to recognize when fewer degrees of
program and earn access to an iPad. He chooses the freedom (greater amounts of coercion) are suitable. For
matching program. (Although there are alternative example, for the most part, all children are required to par-
contingencies, they do not provide the same critical ticipate in reading instruction. However, even at the earli-
consequence; apparent/implicit coercion, zero degrees est stages of intervention or instruction, it may be possible
of freedom to obtain critical consequence) to insert opportunities for assent, and such opportunities
7. EG: An alpaca living in a petting zoo, interacting with should be increasingly embedded over time. For example,
either a zoo guest or a trainer, is provided access to food even though the child was afforded zero degrees of free-
by posing for a selfie, making eye contact with the trainer, dom to participate in therapy, the therapist may provide
touching a target with nose, touching a guest’s cheek with several alternative programs that may provide the same
their nose, or gaining access to food in a food trough. critical consequences, allowing for other “program-intrin-
8. NEG: A goat living in a petting zoo is provided access sic” (program specific) reinforcers to have their effect.
to food only by posing for a selfie. (Apparent assent, Morris et al. (2021) conducted a literature review of jour-
zero degrees of freedom) nals listed on the website of two prominent behavior analysis
9. EG: Jimmy is participating in a tacting program. He is organizations, Association for Behavior Analysis Interna-
required to complete 10 trials to gain access to a tablet, tional (ABAI) and the Behavior Analysis Certification Board
however he can also request the tablet at any time and (BACB) using the search engine Google Scholar to ascer-
receive access. At trial number 6, Jimmy requests the tain if and what procedures are used to determine assent
tablet. The teacher provides access to the tablet. (The in behavior analytic research. Of the 16 journals searched,
teacher evaluates the program prior to the next session) a total 226 articles were identified that included the word
10. NEG: Sally is participating in a matching program. “assent” out of 23,447 total articles (0.96%). Of the arti-
She is required to complete 10 trials to gain access to cles included, 39 were excluded leaving 187 articles to code
a tablet. At trial number 4, Sally walks away from the along four dimensions of assent: “Waived,” “No Detail,”
table and asks a teacher she was not working with for “Minimum Detail,” and “Detailed” (p. 5). Given the limited
the tablet. The teacher tells Sally she needs to complete scope of assent in behavior analytic research, the authors
the rest of her program before she can have the tablet. proposed creating an empirically validated framework for
providing assent but noted that this may be difficult due to a
Degrees of Coercion lack of spoken and written repertoires for individuals diag-
nosed with autism spectrum disorder or developmental dis-
Goldiamond (1976) was hesitant to provide a complete math- abilities. Work with both humans and animals (Abdel-Jalil
ematical representation of coercion, but recognized that the et al. 2023; Layng & Abdel-Jalil, 2022) demonstrates the
two are inversely related—as degrees of freedom increase, applicability of the definition of genuine assent such that
degrees of coercion decrease and vice versa. By this defini- assent is defined through access to critical reinforcers, not
tion, as stated by Goldiamond, “. . . the issue is never coer- the ability to say, “yes” or “no.” We recommend behavior
cion versus no coercion. . . . The issue is the amount and analytic practitioners attempt to constructionally provide at
type of coercion we are willing to accept, and the protections least one degree of freedom wherever it is possible. This will
against abuse we set up” (p. 23). The greater degrees of free- allow for the separate assessment of program intrinsic con-
dom, the less coercion. Even with one degree of freedom, the sequences that would otherwise be over looked. In addition,
participant is still coerced into making one of two choices. As we recommend the elimination of implicit coercive prac-
degrees of freedom increase, there is less coercion. However, tices based on positive reinforcement including many DRO
even with only one degree of freedom, the activity specific and DRA procedures, and abandon compulsion, including
consequences can still have some effect, where they cannot escape extinction and planned ignoring, with the possible
if there are zero degrees of freedom. This allows for con- exception being cases where procedures are required to keep
tinuous program evaluation. Where a participant continually a person from seriously harming themselves or others.
Behavior Analysis in Practice

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