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AS CLIENTS -- “KNOWN BY THE SCARS” (Gal. 6:17)

Autism Conference, Mansfield, BrisbaneQctober 26, 2013

“Being different is what sets you apart from everybody else in this world. It allows you to be unique. It allows you to process information in ways that people will never understand, and see things in ways that others find unimaginable. It allows you to break free from the mold of society. You are not the same as anybody else, yet you are no different to anybody else.

You are YOU… Don’t lose sight of this truth!”-Autistic-ally Beautiful

+Firstly – What is Autism?

Autism is a generalized term describing a complex spectrum of brain development (i.e. neurodiversity)

Because of the differing degrees and variety of characterizations, the term Autism Spectrum Conditions (ASC) is often used to describe the entire range.

+Firstly – What is Autism?

Autism is generally characterized, in varying degrees, by distinct differences in social interactions, verbal and nonverbal communication and repetitive behaviours. (i.e. ‘stimming’ or perservations). These so-called symptoms fall on a spectrum, which help account for the variations in characteristics from person to person.

+Misconceptions (Myths) about AS

• If a person has AS, they are mentally challenged• A person with AS can’t think, feel or express emotion• People with AS don’t understand humor• If someone has AS, then they are simply an introvert

who does not want friendship• All people with AS are the same• Anyone with AS will struggle to be good at anything• Someone with AS is weird or seems a bit odd — but

their eccentricities will pass over time…

(Dominant Ideas that influence how we interact with Autistic people)

+So then – What isAsperger’s Syndrome?• Between 1994 - 1999, the DSM – IV described

Asperger’s Syndrome as a response to a common misconception of a link between autism and intellectual impairment.

+So then – What isAsperger’s Syndrome?• In mid-2000’s, considerable controversy raised about

whether AS and HFA differed qualitatively or quantitatively (Frith, 2004; Howlin, 2002; Miller & Ozonoff, 2000).

• In 2012, the DSM – 5 eliminated Asperger's Syndrome and replaced it with Social Communication Disorder as a sub-type of the family of Autism Disorders.

From my own experience, ASpie’s often present as:

• Articulate• Intelligent• Often opinionated• Seen as effusive• Inflexible (change is unwelcome; B & W views)• Quirky, Eccentric or “Nerdy”• Lonely• Confused / flappable• Very often angry at life

 If, as a therapist, you suspect your client might be AS, then what?

What does an AS Client look like?

+DOES MODALITY MATTER?

ASpie’s tend to push everything they encounter through what I term the “logic gate”. As such, three things seem paramount to modality.Let’s look at several facets of this that seem to make a difference therapeutically --- • Cognitive Functioning• Perceptual Experience• Emotional Reactivity

(Ideas that may influence WHAT MODALITY we might want to consider)

+DOES MODALITY MATTER?

Thinking processes– ‘Specialist’ mind

The patterned thinker

Abstract thinkers i.e. engineers, computer programmers

Verbal thinkers

– Memory capacities

Eidetic memory (visual, anterior cingulate cortex)

Task-specific working memory

 

Heightened sensory-perceptual behaviours and emotional (empathic) lability/ capacity

How does the client “see” their own emotional quotient (EQ)?

Do they tend to put sensory info into categories?

How do they understand “meltdowns” if they experience them?

 

Communication and Relational understandingsInterrupt others frequently; egocentric perspective

Repetitive style (say the same thing 4-5 different ways)

Go around & around the barn (never through it) yet demand the latter of others!

Cannot understand why/how their own behaviours affect others

Do they have any life experiences that ever demonstrated “bridges to empathy”?

(Ideas that influence WHAT MODALITY we might want to consider)

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+Comparison of viewpoints

“AS is ‘personified’ by what one might call the “Holy Trinity” of differences -- a triad consisting of marked differences in communication, social skills, and cognitive and behavioural inflexibility.” 

“With AS, inflexibility is manifested as a dislike and avoidance of change and can also be the presence of obsessional ideation. Many persons with AS are typified as ‘idealists’, and often see themselves as ‘perfectionists’ and ‘realists’.”

“Many adults with AS can “hold it together” with single-minded concentration on an academic or vocational skill that allows them to make use of their often well-developed systematic thinking abilities.”

(Ghaziuddin M, 2003)

From my clinical experience, I consider ASpie’s to have a different, not defective, way of thinking. The person may:

Have a strong desire to seek knowledge, truth and perfection with a different set of priorities than would be expected with other people.

Have a different perception of situations and sensory experiences. The overriding priority may be to solve a problem rather than satisfy the social or emotional needs of others.

value being creative, rather than co-operative. perceive errors that are not apparent to others,

giving considerable attention to detail, rather than noticing the ‘big picture’.

be renowned for being direct, speaking their mind and being honest and determined and having a strong sense of social justice.

actively seek (and even enjoy) solitude. be a loyal friend and have a distinct sense of

humour.

(Attwood T, 2005)

CLINICAL NON-CLINICAL

+Comparison of viewpoints

Many AS adults are employed and married with families: often having developed adequate social behaviors. What they often lack is a deeper understanding of other people’s unspoken intentions or motivations in communication, their “hidden agendas.” AS adults do not understand “office politics” and, therefore, make repeated mistakes in their dealings with others at work. They are often unaware of the role their social behaviors may play in their relational issues. In other words, they lack “Theory of Mind”…

(Ghaziuddin M, 2003)

Social anxiety is common among adults with AS, but it is proposed that this anxiety derives from a different source from the anxiety experienced in social phobia. Many adults claim they have anxiety related to their inability to anticipate what might happen in social situations. Thus, individuals with social phobia are made anxious by what they misinterpret; individuals with AS are made anxious by what they cannot interpret…

(Attwood T, 2005)

CLINICAL NON-CLINICAL

+Neurological considerations

Neural wiring in an AS cortex can be 2.4 to 10X as dense as that imaged in a non-AS brain

For visual thinkers, we know that certain neural pathways are “enhanced” i.e. Temple Grandin’s visual cortex scan (fMRI)

Non- AS T Grandin’s

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Language = use of ‘visual language’, metaphorical i.e. “How does that look to you?” instead of “How does that make you feel?”

Focus on these

VISUALTHINKERS

STRENGTHS

Mind

HeartMOST HELPFUL: use imagery where possible i.e. “heart-mind struggle”

The person with Asperger’s Syndrome can have difficulty with the management and expression of emotions. There may also be problems expressing the degree of love and affection expected by others.

Regarding emotional regulation, many ASpie’s seem to notice having an inability or an exaggerated emotional reactivity.

(Hill, Winston & Frith, 2006)

THE AFFECTIVE REALM– DEALING WITH EMOTIONALITY

+3-brain theory

Nathan Mikarere-Wallis (2013) speaks to the ‘triune brain theory’… in order to get a better grasp of emotional reactivity, it helps that the therapists strives to ensure we ask our clients to develop their 3rd Brain:•  First, calm Brain #1 ( the

brain stem)• Validate Brain #2 ( the Limbic

system) where endorphins, adrenaline, and thus emotions, rule!

• Try to speak to Brain #3 (frontal cortex)

Taken from http://www.radionz.co.nz/national/programmes/ninetonoon/audio/2560924/parenting-with-nathan-mikaere-wallis

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OCCASIONAL SENSORY OVERLOADpeculiar perceptions and difficulties in the processing of sensory information with occasional overload.

problems in processing information from more than one modality.

(Chamak, Bonniau, Jaunay & Cohen, 2008, pp. 274-76)

Most Aspie’s call these “meltdowns”

SOCIALCONVENTION

S

PROCESSINGINFORMATION

EMOTIONALREGULATION

+Can Aspie’s feel Empathy?

Studies assessing the ability of individuals with ASC to identify emotions and mental states from context have also shown deficits relative to the general population or to other clinical control groups (Baron-Cohen, Leslie & Frith, 1986; Fein, Lucci, Braverman & Waterhouse, 1992). These difficulties may be related to a failure to pick up the right emotional cues, and/or to a failure integrating them, explained by weak central coherence in the cognitive level (Frith, 1989), and under-connectivity between brain regions in the neuro-biological level (Belmonte, Allen, et al., 2004; Belmonte, Cook, et al., 2004; Critchley et al., 2000)

(Chapman & Baron-Cohen , 2006)

“… what if what looks like coldness to the outside world is a response to being overwhelmed by emotion – an excess of empathy, not a lack of it? This idea resonates with many people on the spectrum and their families. It also jibes with the "intense world" theory, a new way of thinking about the nature of autism.

The problem is that it all comes in faster than most can process it. There are those who say autistic people don't feel enough. We're saying exactly the opposite: They feel too much.“

(Markram & Rinaldi, 2007)

CLINICAL NON-CLINICAL

“THEORY OF MIND” ARGUEMENT

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Can Aspie’s feel Empathy?

Empathy may appear absent for one of a several reasons—either:

1. because we feel it but don't know how to express it;

2. because we simply can't relate to a situation—i.e. it's something we've never experienced before so we don't know how it feels, or,

3. because we feel shame so we shut down to self-protect.

"If anything, I struggle with having too much empathy", one person says. "If someone else is upset, I am upset. There were times during college when other people were misbehaving and, if the teacher scolded them, I felt like they were scolding me.“

(Client #3 aged 22)

COMPLEX / INTENSE WORLD THEORY

+COMORBIDITY

Alexithymia — have great difficulty identifying and describing internal emotional states

Anhedonia — the inability to experience pleasure from activities usually found enjoyable, e.g. exercise, hobbies, music, sexual activities or social interactions. May result from the breakdown in the brain's reward system, involving the neurotransmitter dopamine.

ADHD, BMD, OCD, anxiety/depression

Tourette’s syndrome — very common comorbidities

(Simonoff et al., 2008)

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Aspie’s and Depression

1. “Tantrum” (temper) meltdowns

2. “Depressive” meltdowns

3. “Bridge burning” phenomina

1. Over pretty quickly and physical fallout over with in a few hours; explosive, devastating.

2. Can last for days or even weeks and are incredibly crippling, intense, and psychosomatically debilitating.

3. Described as being hit with a baseball bat in the belly and the head, simultaneously. Some clients have even described it as “being paralyzed with grief”

(Simone R, 2012)

LOSS OF POWER triggers “meltdowns”

+My Pet Curiosity

1. the result of depression meltdowns. The clouds won't lift so new horizons are sought.

2. the end result of temper meltdowns. If an ASpie gets very angry… they resolve never to deal with them/it again.

3. sort of psychic pyromania. It’s often triggered by many of the same things; it's the last straw of being misunderstood.

“I get depressed, get very low, kick out at everything and everyone. Hate my life, hate myself, hate the people around me. I get out of it by changing as much around me as possible — quit a job, leave a relationship, sell my house, etc.”

(Simone R, 2012, p. 183)

“BRIDGE BURNING” PHENOMINA

+IMPORTANT THERAPEUTIC FACTORS FOR AS CLIENTS

Establish a Supportive (Empathic) Therapeutic Connection (i.e. relationship)

How do we do this if the client can’t even tell the therapist what he’s feeling?

Theory of Mind = is this even possible for ASpies?

Can we successfully communicate a caring attitude?

 

Establish an ‘early warning’ system for communications breakdown 

Using the therapeutic relationship as a laboratory for developing new social behaviours i.e. alternatives to meltdowns; coping with change;  

Using specific examples of situations encountered in their day-to-day lives.

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o Pharmacotherapyo Narrative therapy (Cashin, 2008)

o Art therapy (Elkis-Abuhoff, 2008)

o Music therapy (Allen, 2010)

o CBT/DBT (Gaus, 2007, 2011)

o Group therapy (Longhurst, 2010)

o Psychotherapy (various)

o Sensory Integration therapy (Dawson, 2000)

o ABA (various)

o TEACCHo ‘Life Coaching’

o (Bromfield R, 2012, p. xx)

THERAPIES THAT OTHERS SAY WORK FOR AS CLIENTS

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Psychotherapies (consdierations)

1. Some researchers believe psychoanalysis and other psychotherapies emphasizing symbolic constructs, introspection, and interpretation have not been found to be helpful in understanding and treating Adult AS (Frith, 1991; Wing, 2001; Borthwick, 2012).

2. Inviting significant others, familiar with the person’s life, into early sessions seems to help therapists get third-party information about the client’s functioning [i.e. “outsider witness”]. (Dallos, 2003; Cashin, 2008).

“Whether therapies …can help adults with autism … is still unclear. Only 32 studies conducted so far of therapies for autism are aimed at adolescents or adults with the disorder (aged 13–30 years), most of which were of poor quality, according to a report published in August 2012 by the US Agency for Healthcare Research and Quality.

Compared with a previous report of 159 studies of treatments that enrolled children 12 years old and under, with autism, it seems adults are merely lost in the shuffle.”

(Borthwick, 2012, p. xx)

WHAT DO WE SUSPECT???

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 “INSIDER INSIGHTS” – AS THERAPIST/AS CLIENT

HIGHLIGHTING SOME OF THE MORE SALIENT THERAPIST & CLIENT ISSUES

+POSSIBLE THERAPIST ISSUESLITERAL COMMENTS MISCONSTRUED

Some adults with AS come across as downright rudenew AS patient speak their truth bluntly – may be taken to heart

 INACCURATE REFLECTIONS / REFRAMING BY THERAPIST IMPLICIT ‘CODIFIED’ RULES

Some adults with AS have developed their own UNIQUE set of codified rules for how others should act that are based on the individual’s egocentric viewpoint (Attwood, 2003)

In my own experience, I’ve met many ASpies that complain when others “breach their boundaries” it is common for them to: (a) cross the bridge, (b) burn the span behind them, never to (c) think of the offender ever again! This seems to be a useful way of ameliorating stressors that lead to ‘meltdowns’.

+POSSIBLE THERAPIST ISSUES (CON’T)FORGIVENESS / ‘LETTING GO’ OF SLIGHTS

COMMON CAUSES OF ANGER IN RELATION TO ASCBeing swamped by multiple tasks or sensory stimulationOther people’s behaviour e.g. being ignored, prejudice or bias, unjust actionsHaving routines and order disruptedDifficulties with employment and relationshipsIntolerance of imperfections in othersBuild-up of anxiety.

IDENTIFYING THE CAUSES OF ANGER can be a challenge! It is important to consider all possible influences relating to the:

Environment e.g. too much stimulation, lack of structure, change of routine.Person’s physical state e.g. pain, tiredness, Person’s mental state, e.g. existing frustration, confusion.Treatment the person experiences by those around them.

Difficulties in gauging how well the therapy is progressing, from the client’s reactions, which may lead to the therapist questioning his / her effectiveness. Become mindful of negative reactions to AS clients and how these reactions might lead them to subtle disengaging from the therapeutic relationship (counter-transference).

+POSSIBLE CLIENT ISSUES

ERRORS OF COMMISSION (COGNITIVE DIFFERENCES – REACTIONS)

1. Establishing a helpful framework for AS individuals to understand their reactions --- and to recognize that there are alternative interpretations of these same social situations.

2. Such factors rely on a therapeutic relationship based on an assumption that feedback will be constructive and focused on reducing social misinterpretations.

ERRORS OF OMMISSION (CONFUSION IN SOCIAL SITUATIONS)3. The therapeutic relationship becomes an impor tant vehicle for exploring social interactions, and therapeutic conversations provide opportunities for looking for available ‘social cues’ that could be useful / helpful in avoiding these types of faux pas.