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Autism/Aspergers – Working together in the therapy room (mini-series- pt.6)



Hi, and welcome to this week’s post, part 5 in my series about working together in the therapy room with autistic clients.

This week I’d like to talk about what goes on in therapy. There might be “set-backs”, there might be a need to set clear goals in order to set the client up for success, and using problem-solving approaches might help with this.


Read part 1, 2 , 3 , 4, 5 here.

I’ve also written a few posts about what to expect on your first counselling session (read part 1 and part 2 here).

You can also click here for my other posts on Autism.


For these posts, I’d like to reference Katherine Paxton and Irene A. Estay’s book called Counselling people on the Autism Spectrum (chapter 3)


In the intro for this post I wrote “set-backs”.

This is something that I don’t consider the correct wording, but clients might use this language, so let’s go with it.

I trust in the work that we do in each session with my clients.

Sometimes therapy is counter-intuitive.

Clients might get worse before they get better, and riding that out might be tricky to understand or grasp.


Explaining – psychoeducating – an autistic client about the fact that this is going to happen and how it might look like, in general terms, might help keep the anxiety about these “set backs” to a low level.

Working through the anxiety of feeling like we took some steps forward and coming back for a future session thinking that the work has been undone is something I’m familiar with.

It happens with both autistic and non-autistic clients. It’s all part of the process.


Using visual aids or diagrams might help clients understand this and trust that what they’re doing is getting them ahead rather than falling behind.

I trust that, in the way we work in the room, once we have taken steps forward, we can never go back to square one.

There might be the chance of going back 3 steps but never the 10 we’ve already walked.

The change that happens is organic most of the time, and if it hasn’t “clicked” yet, then it just means we need to continue working until we have reached the full depths of the origin of the issue.


Therapy is like an archaeological dig or a police investigation. We are connecting the dots, putting things back together in order to get a clear picture and set goals to move forward.

Setting clear goals is something that I don’t do in an overt fashion with my clients, but it might actually be very helpful to focus the mind of an autistic client.


Using problem-solving approaches might be ideal to support an autistic client with what they want to work through.

There might be the need for some flexibility within the goal and how to reach it, following my usual way of working (free association) but having that goal will allow us to focus and possibly measure the changes as we go through the sessions.

Figuring out in therapy how to get from A to B, and what will be helpful to each individual client is important and is something that we learn together as client and therapist.


Until next week…


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Autism/Aspergers – Working together in the therapy room (mini-series- pt.5)



Hi, and welcome to this week’s post, part 5 in my series about working together in the therapy room with autistic clients.

This week I want to talk about transitions, anxiety, autonomy, self-esteem and self-talk.


Read part 1, 2 , 3 and 4 here.

I’ve also written a few posts about what to expect on your first counselling session (read part 1 and part 2 here).

You can also click here for my other posts on Autism.


For these posts, I’d like to reference Katherine Paxton and Irene A. Estay’s book called Counselling people on the Autism Spectrum (chapter 3)


Transitions


I’ve been working with autistic adults and young people for 11 years now in the care sector, and 5 years with counselling clients.

Something that’s clear from this time, is that transitions can be hard!

Staff change-overs might cause distress as there might be more people walking around and therefore maybe more noise and uncertainty for that half hour.

It has been easily alleviated by staff coming in straight to the office, to keep the environment calm and familiar for the individuals.

A social story (mentioned in the previous blog post) might be used to inform the residents about who is leaving and who’s taking their place. This brings reassurance and calm to them.


In the therapy room, it might help to stick to the same time and day for sessions, as well as having a routine set for the hour.

I’d say the best way to do this is ask the client what would work best for them at the start of the session, during the session, and at the end of the session.

At the start of the session, the therapist might have arranged the cushions in a particular way, left some stimming objects (like a stress ball or playdough or something else) near the client’s chair which they can access if needed.

The client might bring their own, which is very welcome in my room as it will be helpful for the client to have familiar things, especially at the beginning of the process.

Leaving the windows open or closed has also come up in my sessions, and I make sure I ask the clients what’s better for them. This will change as the therapeutic relationship changes and the room becomes more familiar to the autistic client.


During the session, checking in often about how the session is going and how the client is feeling, what needs changing or working on, will be helpful and reassure the client that they’re being heard and understood.

At the end of the session, the client might need a transition “ritual” or a few steps that might help them close down what was opened up during the session.

Maybe some processing time or some checking in with the surroundings and the next steps.

It is all person-centred, so this will be different for each client, as their transitioning needs and experiences might also be very different.


Anxiety


I’ve previously written some blog posts on anxiety, which you can read here (part 1, part 2, part 3)


Anxiety with autistics can be linked to transitions.

Sometimes an advanced warning with plenty of time to process might help the client with the transition by helping keep the anxiety at bay.

Other times having such an advanced warning might be anxiety provoking in itself. Keeping the warning to just before the transition is happening might be helpful in these cases.

Keeping clear on what’s going to happen next, and sticking to what we say, can be really helpful.

In the therapy room, if we say the session will last 50 minutes, make sure you stick to this time.

Ask the client whether a 5 or 10 minute warning would help, or whether you just end the session at 50 minutes without much warning.

A cue such as grabbing my diary to schedule the next session might become a transition clue for the client that the session is ending. This might develop naturally or as part of the conversations and agreements in session 1.


Do read my series on anxiety for more on this topic.


Autonomy


As part of the ethical frameworks I work under, respecting the client and providing a space for them to be autonomous is essential, and ethical, in the therapeutic relationship.

By asking questions like the ones described above, we are setting the client up for going from depending a bit on the therapist to understand their inner world and their relationships, to learning how to tap into these on their own, as time goes on.

The goal with therapy is not to keep a client forever, it’s to enable autonomous behaviours and thoughts, through practice.

By observing what goes on in the therapy room, which is usually a reproduction of what goes on in the client’s everyday world, and discussing their everyday events and past situations, the client becomes able to process their thoughts, emotions and events on their own, slowly through their therapeutic journey.

Seeing clients come into the room and talk about their progress with setting boundaries or asking for their needs to be met, or having an “a-ha” moment about something we’d been discussin in therapy, is so rewarding and it is great to see the therapy taking an effect in the clients’ lives.

Autonomy is essential in the client’s self-esteem and ability to live their best lives. Of course other aspects are also involved.

Estay and Paxton call this self-monitoring in Chapter 3 of their book.


Self-esteem and self-talk.


Focusing on the positive things clients say to themselves can be helpful when negative self-talk has been taking a hold of the client’s life.

Self-esteem can increase and the client’s moods and how they go about their daily lives can be impacted greatly by focusing on the positives.

I read somewhere (can’t remember where) that thinking that is not reinforced will be come extinct.

The same goes with thinking that is reinforced. It will be at the forefront of the client’s mind.

So if we don’t reinforce negative thoughts, then we can focus on the positive ones.

This seems to work well for autistic clients, and I tend to use it with many of my clients, in one form or another.


Keep speaking positive into your life, and I’ll see you again for next week’s post.


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Autism/Aspergers – Working together in the therapy room (mini-series- pt.3)


Hi, and welcome to this week’s post, part 3 in my series about working together in the therapy room with autistic clients.

In this post, I’ll discuss how autistic people might benefit from thinking about how many of their behaviours might be due to the fact that they are human, and not because of autism, although they might still be tinted by the different wiring that comes with autism.


Read part 1 and 2 here.

I’ve also written a few posts about what to expect on your first counselling session (read part 1 and part 2 here).

You can also click here for my other posts on Autism.

For these posts, I’d like to reference Katherine Paxton and Irene A. Estay’s book called Counselling people on the Autism Spectrum (chapter 3)


Let’s start with what I mean by some behaviour being nothing more than human behaviour.

There have been many instances where I’ve been talking to an autistic person and I’ve thought “hang on but I do that too”.

Now I’m not saying that our experiences, even though similar, aren’t experienced in very different ways.


(I felt “over-sensoried” the other day, but that was just because I hadn’t slept well and had lots to do and was getting overwhelmed to the point that I couldn’t have the radio on while working, for that few hours in the day. This is different from having a sensory sensitivity as an autistic, which doesn’t go away with a bit of sleep).


It is all about meeting the person where they are, and understanding how the situation led them to react a particular way, which might be similar to how I’ve responded but not with the same considerations.

It might be because I’ve been around autistic people, young and old, for many years now, and I can relate and really understand what’s going on.

It also helps building a relationship with my clients and getting to know them, their triggers, the systems they’ve created to help them with daily life, amongst other things.


For example, I know that when I’ve said to a client something like “I think this might be because you’re human”, it has been reassuring.

Sometimes clients will say they wonder if they’re that different, if it was their autism that led to that breakup or that conversation turning into an argument.

If we go with the thinking behind theory of mind, it might be a possibility that a social cue was missed and that led to the argument. But it might also be the case that the argument was going to happen anyway, cues or not, because the relationship was going in that direction.


We have to take these a situation at a time. Without context, what I’m saying might be misinterpreted as being dismissive of the autistic person’s experience.

As I write this, I realise that what I’m doing is seeing the person in front of me as a whole individual, yes with different “wiring” but still a human being.

And this is why it makes sense to qualify behaviours as “human” because we are all humans, with our particular individual differences.


Until next week…


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Autism/Aspergers – Working together in the therapy room (mini-series- pt.2)

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Hi, and welcome to this week’s post, part 2 in my series about working together in the therapy room with autistic clients.

In this post, I’ll discuss a few ways in which I might work slightly differently than with neurotypical clients, and how this will help those on the spectrum get their life back on track.

For these posts, I’d like to reference Katherine Paxton and Irene A. Estay’s book called Counselling people on the Autism Spectrum (chapter 3). 


If you missed part 1, read it here.

I’ve also written a few posts about what to expect on your first counselling session (read part 1 and part 2 here).

You can also click here for my other posts on Autism.


 

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I believe in the power of the therapeutic relationship, and having clear communication in how we are going to work in the room is important to start developing a relationship that will help the client understand what is going on for them and how to work through it with the help of their therapist.

In this post, I’ll talk about contracting, boundaries, how to approach each session, and how language can help or hinder the process.

 


Contracting and Boundaries

Contracting is an important aspect of any and every counselling relationship. I usually send my contract out and let the client read it on their own and during the session just ask if everything is clear and if they have any questions.

According to Attwood (2003, in Paxton and Estay), contracting with someone with Autism will need to be very concrete, both regarding the contract itself but also the issues and symptoms that will be dealt with.

Too broad and the focus will be lost. The process needs to be very specific.


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I find that with all my clients at different points of therapy, they might need a reminder of what was in the contract – one of the ones that comes up the most is late cancellations, but there might be others, like communication outside the therapeutic hour for things other than rescheduling or asking to confirm what time we are meeting next week.

This is no different with someone on the Spectrum – the only difference is the way it is said.

This will depend on where on the spectrum my client is – with some clients, I have pictorial contracts in the form of social stories (we will talk more about these in next week’s blog post), which are simple and short ways of defining what is going to happen, with whom, where and how.

I also have a summary of my contract, which might be too “busy” and a client might get over-sensoried or overwhelmed with too much information in the unabridged version.


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The how is another issue that all clients might struggle with.

 

The way of thinking, working and relating in the therapy room is very different from any other relationship.

The focus is on the client and not the therapist, who keeps self-disclosures to a minimum.

The first few sessions might be a learning about how the process works, why the therapist is asking this or that, which might require the therapist to be very concrete and clear on the purpose of each intervention and question:

how is this going to help the client, and why this seems to be a good question for the therapist to ask.


Some basic things that we need to get through to our clients on the first sessions, according to Paxton and Estay, are:

  • social ground rules for the therapeutic relationship
  • turn taking and sharing of information

    • what does the therapist need to know
  • contact outside of sessions and the purpose of this contact (usually for rescheduling or cancelling a session)

  • how the work requires a partnership between client and therapist – the client is not on their own, they have the support of their therapist to help them work through the issues that bring them to therapy at this point in time


Keeping it literal

I use metaphors in the therapy room.

Usually these metaphors come from something a client says and becomes something we can refer back to in future sessions.

 

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These metaphors are helpful as they are developed through the therapeutic relationship and the variety of interactions between client and therapist.

They are also helpful because they might point towards a certain pattern of behaviours or thoughts we might be working through with the client, which will help change the way they think about this and find better ways or new ways to be in the world.


Here is a difference when working with people with Autism: it might be tricky to understand that the therapist (or anyone else) is speaking using innuendo or double meaning.

This is why it is very important that the metaphor is developed with each individual client and not used at random – although sometimes this might also be helpful.

Another aspect of working with someone with Autism might be, as mentioned above, that emotions and feelings are not concrete entities.

Working might need to happen more at a thought level rather than a feeling level – reaching the feeling level through thinking about said feeling.

Also, if clients don’t see a specific thing as an issue (let’s say, in couples therapy), they might never mention it unless the partner or therapist bring it to their attention.


8Theory of mind is another aspect to take into account.

My autistic client might not understand that the way they speak to their partner is making them upset, or they might not see that a particular way of thinking is held only by them.

As I discussed in another post, people with Autism might have developed very intricate systems in order to practice empathy.

This might relate to very specific situations, which doesn’t mean the systems can’t be used to the therapy’s advantage.

As a therapist, it’s my job to challenge and provoke thought in my clients.

Challenging a particular system in a way that opens it up to other situations, behaviours, thoughts and interactions, will help the client develop their system of empathy (and other systems), which will help them develop more coping and relating mechanisms in their daily lives outside the therapy room.


Finally, processing times might differ from client to client, and this includes my Autistic clients.

Being respectful of this is key in my work with all clients, and being mindful that it might take a few tries and quite a few sessions for something to start clicking and making sense to my autistic client is very important.

Giving the client written notes of the sessions might help. As a firm believer in helping your client be autonomous, giving the client the choice of doing this themselves might be a good way to do this.

Some of my autistic clients bring their notebooks and write down what they feel is relevant for them to go back to during the week.

In future posts, we will talk about using creative techniques, such as diagrams, using the whiteboard and charts to find evidence for or against certain situations and ways the client might have worked through particular things.


I’m a big fan of celebrating all our wins, and this will be obvious in the work we do together.

I’m also a fan of working to the clients’ strengths, which in the case of autistic clients, might start with their ability to use visual thinking and concrete processing.


I hope you enjoyed this post.

Do leave your feedback at the bottom of this post and contact me if you want me to add anything or amend anything – I will not always get it right!


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Autism/Aspergers – Working together in the therapy room (mini-series- pt.1)

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Hi, and welcome to this week’s post, in which I’ll be focusing on a topic and group of people I’m very fond of and really enjoy working with.

I’ve written a few posts about what to expect on your first counselling session (read part 1 and part 2 here).

In this mini-series, I’d like to add a few things about how I might work with someone on the Autism Spectrum.


2I leave it as “Autism Spectrum” as it’s not a condition or a disorder, it’s a way of being, and this is the first thing I want my clients to understand — I get it, I get that you are individuals just like everyone else, and as such I’ll treat you like individuals and focus on those things that you want to work on, just like I do with everyone else, but taking into account the diverse ways of processing, thinking and being in the world you might come with.

The word “spectrum” also leads us to a broader aspect of Autism – everyone on the spectrum is different. I’ve never met two people on the spectrum that thought or behaved or had the same exact personality.

It’s the same as with everybody else, but it’s harder for some to understand because it’s something that’s just becoming more common place now to talk about, or to know a lot about for that matter!


(even professionals struggle with Autism, and this really needs to change!)


This is why I offer the service of counselling people on the Autism Spectrum, because I’ve learned through the years how to listen, how to talk or stop talking, how to work with people at different levels of the spectrum.

In my care job I have worked with people with severe to mild to high functioning autism, but the role there is very different of course.

In counselling I mostly see people with Aspergers or High-Functioning.

The topics I work on are very similar to the ones I work on with my other clients, but they might take a different meaning and way of working through them.

As you’ve read in my past posts about autism, for example, empathy is more of a structured process rather than a mainstream way of empathising, but that doesn’t mean it’s not there.


3Click here for my other posts on Autism.


For these posts, I’d like to reference Katherine Paxton and Irene A. Estay’s book called Counselling people on the Autism Spectrum (chapter 3). 


I’ll leave an outline of what I’ll be talking about in the next posts of this mini-series.

If you have any questions or further suggestions, do let me know and I’ll be happy to add them to my blog posts!


Mini-Series Topics:


  • Contracting
  • Boundaries
  • Focus of the sessions
  • Keeping it literal
  • processing time
  • what’s behaviour due to “autism” and what’s just “human” behaviour
  • alternative ways of working – writing, play, diagrams, social stories (Carol Gray)
  • cognitive restructuring
    • working on the thinking process – empathy by the therapist is key
    • working on social cues and rules
    • responsibility
    • choices
  • using metaphors
  • addressing “set-backs” in the process of therapy
  • goal setting
  • problem-solving approaches
  • transitions
  • anxiety, etc.
  • autonomy helps with self-esteem and with our place in the world
  • how we talk to ourselves has an impact on how we behave and think
  • setting the client up for success

See you in next week’s post!


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Empathy and Autism

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Hi, and welcome to this edition of my Autism series posts.

I hope you enjoy it.

If there is anything you’d like to know about Autism that I can write about, do let me know by using the contact form on the main menu, or leaving a message at the bottom of this post.


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It is regularly thought that people on the Autism spectrum can’t or don’t empathise.

I’d like to challenge that from a couple of different angles.

First, from personal experience.

Second, from the perspective I’ve read in Paxton and Estay’s book on Counselling people on the Spectrum.


I’ve worked with people with Autism for the past 11 years.

Each individual is different – as we all are – and has different abilities and personalities which make them unique and great to be around.

I’ve had empathy from autistic people I’ve supported, so I know that I can challenge this from personal experience.

A pat on the back when I seem sad.

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An attempt to make me laugh when someone has angered me.

Laughing at something funny we both happen to see at the same time, and knowing we are both laughing at that exact same thing.

Whether it’s “mainstream” empathy or not, does it really matter?


The general definition of empathy is to have the ability to identify someone else’s emotions or thoughts and respond appropriately.

Don’t the few examples I mentioned above fit into this?

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I think they do.

Right.

I think I’ve made point one quite nicely, with the help of those people that have changed my life through their particular approaches to life and relationships.


Point two – Paxton and Estay suggest that autistic empathy is more about systems than what we usually recognise within ourselves when we feel empathy towards another person.

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They say that “systemizing is described as the ability to understand and build systems, and predict how a system will perform given certain conditions. Systems can be mechanical, natural, envorinmental, technical, abstract or taxonomic. they do not include human systems – family, office.”

I agree with this, as I’ve challenged clients on the spectrum before with things such as:


“Well you say that when someone has their arms folded, it means that they’re being defensive. This might be the case some of the time. Other times I might fold my arms because I’m cold or I’m thinking and this helps me think.”


I work with people on the spectrum in a similar way that I would with anybody else, as you can see from that verbatim above. I challenge views and allow for space to think about alternatives.

In the case of someone on the spectrum, even more sensitivity needs to be used, as it has taken the individual quite a lot of time and effort to come to this conclusion.

It is by no means a wrong conclusion.

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It might just be incomplete, and my job as their counsellor would be to fill in the gaps, so that their empathic system has even more options and alternatives of what someone’s behaviour – i.e. folding their arms – might mean, and therefore allow even more responses – i.e. being defensive back or offering a blanket!


Systems help people function.

They help people empathise in a particularly clever way.

Whether someone on the spectrum empathises with you in the more “traditional” way or via the systems they’ve built, they are still being empathic towards you.

I believe there’s a lot to learn about how adaptable and how people with different brains than us neurotypicals can adapt to this world we live in.

We struggle. They struggle.

We are all human living in an imperfect world.

Let’s embrace everyone as they are. Let’s learn and grow from knowing one another, warts and all.


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Autism Spectrum Series – Theory of Mind

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Welcome to this week’s In Therapy post.

In this week’s Autism Spectrum series, I want to discuss theory of mind, as it is an important aspect of social communication, and a big part of the difficulties that someone on the Spectrum might experience.


1I find it amazing how people on the Spectrum, particularly Aspergers, find ways to figure out how to navigate the sea of social communication that we take for granted as neurotypicals.

It is amazing but also, to them, to be expected as it is a skill and a tool for survival and for living in a mainly mainstream world.


In brief, theory of mind explains how people understand someone else’s point of view, including what they know, what they believe, their emotions and intentions. This understanding in turn helps to navigate the sea of social communication and situations we discussed last week.

It is similar to empathy, only differing in that empathy allows the person to feel what the other is feeling, whereas theory of mind stops at the understanding that someone might have different feelings to themselves.

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Sometimes people might struggle with social interactions because they might believe that everyone believes and thinks exactly the same way as they do.


In neurotypical children, theory of mind – knowing that others might have different beliefs, knowledge or emotions about things – starts to develop at the age of 3-5 years, while in those on the Autism Spectrum it might begin to develop between the ages of 5-13, but it might not develop to the same level of the neurotypical children.

This is a good predictor or aspect important in diagnosing Autism or Aspergers.


The opposite of theory of mind is mind-blindness.


3Knowing that theory of mind is an area to be worked on, and following from what I said last week about challenging the individual’s learned view of a particular situation (remember the folding of the arms scenario), providing skills to develop social skills in understanding others’ reactions and beliefs is an important aspect of the therapy or coaching process.

For example, in the folding of the arms scenario, the individual with Autism trying to figure out what the folded arms mean, might react aggressively because they might believe the person is angry with them and they are trying to defend themselves from this anger.

If we analyse this scenario with the individual, and explore other reason for the other person having their arms folded, we might see their behaviours change – if the person is just feeling cold, the individual might offer them a jumper or try to get them a hot drink to warm up.

4In therapy, I use this technique with my mainstream clients, in a similar way but possibly in a more cognitive way, in more abstract terms; whereas with someone with Autism it might need to be discussed in a more objective, tangible, behavioural way.

That is not to say that I wouldn’t or haven’t used both ways of working with my clients on the Spectrum.

It’s just about finding the right words and ways to make things easy to grasp, to get that “aha” moment that effects change in therapy.

Same idea, different process.


Theory of mind is one aspect of social communication and interaction, but it goes even further than just preventing someone from understanding another person’s beliefs, emotions and intentions.

As a consequence of the difficulty in figuring these out, the following areas of social interactions are also affected: having meaningful conversations, resolving problems, having intimate relationships, to name a few.

5This can be highly frustrating, leading to “meltdowns” or broken relationships if not picked up soon enough.


Having said that, most humans have broken relationships – so it is important to normalise that these broken relationships aren’t privy to people on the Spectrum. We all fail at communicating well what we think or feel, especially to those closest to us.

Becoming aware of this and learning from our mistakes is going to make the difference in our next relationships.


Understanding how this area of functioning is affected, will provide great insight into the mind of someone on the Spectrum, and therefore allow us to better understand their behaviours and communications, whether verbal or otherwise…

6…they will also allow us to find better ways to teach social interaction skills and ways to guess what the other person is thinking and feeling, and therefore increasing the chance of close relationships, meaningful conversations and increased ability for problem solving.


I trust in the process and I trust in my clients’ capacity to develop all these things, and more!


I have been working with clients on the Spectrum from a cognitive standpoint, in the here-and-now, but also understanding – psycho-dynamically – that some issues that they might be experiencing might stem from childhood experiences or other experiences from the past.

I work in this way with everyone, but pay special attention to the social communication aspects when working with people on the Spectrum.

In my place of work with young people with Autism and other disabilities, we us social stories to help them understand what is happening now, what is going to happen next, where we are going, when we are eating or having a snack, and when we are getting back to the care home after an outing.

7This works very well as it gives them information and therefore lowers anxiety during transitions.


There is a lot of scope to help mainstream individuals understand how people on the Spectrum function and how they have learned to navigate the complex world of social interactions, which in turn will help us show the person on the Spectrum how others think, creating a better environment for everyone.


Understanding is key…


 

 

I welcome your questions and comments below.

Next week I will write more about Intense World Theory.


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