Tuesday, 24 January 2012

Hearts of Glass: Integrative Psychotherapeutic Approaches to Autism

A person with autism is first and foremost, a person. Their needs are no different to the rest of us, especially the need for “connection”, and yet it is exactly this “connection” that is so difficult to achieve through the mask of autism. The presentation of many children with autism is one that removes opportunities for connection – the connections that are so important for the development of a sense of self, and for the development of personality.

In my work in the UK, I see a number of people across the whole range of autism who have poor self-awareness, poor self-esteem and a very fragile personality. Whatever our view of the causes of autism, the effects are very clear, and it is these effects that can be worked through using various psychotherapeutic approaches.

Key Principles

A major clue to opening up pathways of working lies in acknowledging the autism and its effects. Autism is characterised by problems in communication, social understanding, flexibility of thought and sensory integration. These characteristics can create a perception and perspective on the world that is very different to that of other people. If we add a learning disability to the profile, then those perspectives and perceptions will be altered yet further. The core deficits within autism are bound to lead to high levels of social and emotional stress. Understanding these perspectives is vital to successful therapy.

A second clue to successful working is understanding that whilst a person’s autism may be a major feature of that person’s life, there are other things going on for that person as well, as they do for other people. We all operate within an environment; we all have individual personality traits; we all have a genetic inheritance of some sort; and we all have an experience of life. Each of these things affects who we are, and how we react to things. In autism, the impact of these things may be distorted, but that does not mean we should discount them.

Thirdly, a therapist should understand that autism affects those around the individual perhaps at least as much as it does the individual themselves. An awareness of projection, introjection, transference and counter-transference is vital in unravelling the sometimes complicated relationships that can develop around the individual. Understanding a little about group dynamics and disrupted functioning can also be useful.

Other factors

In the UK, and perhaps in other parts of the Western world, we have a very medical and behavioural view of autism. The reliance on a medical perspective risks ignoring emotional stress. A solely behavioural approach risks becoming stuck in “symptom management”. A combination of the medico-behavioural perspectives risks over-reliance on anti-psychotic medication. An integrative and holistic psychotherapeutic approach can help to avoid these risks, and lead to very real and lasting progress.

Another factor involved in poor outcomes and overall prognosis is negativity. A doctor might say to a parent, “I’m sorry, but your child has autism…” A mainstream school might view the autistic child as “a nuisance”. Peers might view the child as “strange” or “odd”. Poor social functioning might create isolation and loneliness. And thus the child may develop a poor self-esteem, low confidence and motivation. These things can then lead to anger, frustration, depression and anxiety as the child grows up. The good news is that these emotional elements are all treatable using psychotherapeutic approaches.

And if we use other language to describe some of the key autistic behaviours, we can see how psychotherapy can help there, too. For example, autistic behaviours are often listed like this:

• A need for “sameness” and routine
• Rituals and obsessions
• Withdrawal
• Physical control – everything in its place
• Physical control – aggression
• Hyperactivity (or is it hyper-reactivity?!)
• Anger

If we call them defensive or reactive behaviours instead, then we can see how psychotherapy aimed at easing social and emotional distress can reduce these, and other, behaviours.

Autism affects those around the individual in various ways. This is sometimes overt, as in the case of a parent who quickly becomes depressed and/or frustrated. Sometimes the effect is more subtle, where these things happen over a longer period of time. But sensitive psychotherapeutic approaches can also benefit everybody within the autistic person’s network. And if the network functions well, it can only be good for the individual at the centre of it.

Useful Approaches

It is essential to build rapport with the individual. This can be done by paying attention to interests and key behaviours. It might be easier to achieve with clients who have a greater intellectual capacity, but it can also be done with people with severe autism and co-morbid learning disabilities, even if they are non-verbal. An approach called “Intensive Interaction” has been developed to enable the forming of connections with severely disabled people. It requires us to “switch off” our natural communication systems, and to mirror key behaviours, thus showing acceptance to the individual. Whichever approach we use, rapport helps us to enter into the world of the autistic person.

We can use the rapport to build up a perspective of the individual’s life – the current situation, the history, and perhaps even the hopes and dreams that the individual has.

Other useful approaches will almost always involve relaxation methods, and the provision of alternatives to negative behaviour. Relaxation helps to lower general arousal levels. For other clients, their perception of the world leaves them under-stimulated. Here we can provide exercise programmes and sensory integration therapies.

Cognitive Behavioural Therapy is often cited as being useful in autistic spectrum conditions, especially for those with Asperger Syndrome. CBT seeks to alter behaviour through changing the way we think about things. Neuro-Linguistic Programming has also been shown to be helpful here. The risk, however, of using CBT by itself is that we can miss the underlying emotional distress, and in some cases it can risk making the situation worse. This is because some people on the autism spectrum display repetitive negative thought patterns (sometimes called ‘ruminative’ or ‘catastrophic’ thinking) – we need to make sure that CBT does not simply exacerbate these symptoms.

The use of creative approaches (music, drama, art, play, story-telling etc) is useful right across the range of disabilities in autism. Such approaches enable emotional expression where previously it was impossible.

“Life-story” work enables the client to re-frame their perspective on life. Many people with autism and depression fixate on negative events in their lives, and effective Life-Story work helps to reconstruct the pattern into a more positive format.

Hypnotherapeutic approaches can also be used. The therapist needs to be mindful of the need for clear informed consent before engaging in direct work of this nature. But there may be one or two hypnotherapeutic techniques which can be used in the course of other therapeutic interventions. We have already talked about the usefulness of relaxation techniques. It might also be possible to use story work to guide imagination towards more positive ends.

Where necessary, a major factor in achieving more positive outcomes is in the use of social skills interventions. If much of the stress and anxiety in autism has its root in social dysfunction, then helping to improve social performance will remove some of this stress.

Other useful approaches will involve anger management and conflict resolution techniques. Anger in autism usually comes from conflict, and conflict usually happens at the point of interaction. We can do a lot to avoid such conflict by improving our understanding of the autistic heart and mind. But sometimes conflict is inevitable, and management techniques will be vital. Providing positive alternatives to anger can be helpful – as long as we do not forget that anger is a natural human emotion, and we all have a right to express it. Suppression will often only lead to further problems.

Psychotherapy at a deeper level, is more difficult, but progress can be made towards improving self-esteem and self-value, as long as the therapist is sensitive to the defences that people build around themselves. Bruno Bettelheim published a book called “The Empty Fortress”. Perhaps this was a mistake – the autistic “fortress” is far from empty. It is very well defended, but it is full of life, vitality and potential. All we have to do is to find a way into the box, remaining sensitive to the reasons that the defences went up in the first place. Some of those reasons have been shown to be pathological, and could well be improved through medical treatment, or physiological interventions (for example, dietary approaches). Perhaps the real challenge is finding the courage to offer holistic and integrative approaches that encompass all these factors, whether emotional or physiological, thereby helping people with autism to become much more integrated, and far less isolated. And part of that challenge might be working towards altering the low value that society places on disability and those living and working with it.

David Moat
Transpersonal Psychotherapist and Hypnotherapist
Training and Advice Consultant, Autistic Spectrum Conditions

01223 315400 or 07734420997

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