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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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Autism Spectrum Series – Navigating the sea of social communication

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Welcome to this week’s In Therapy installment of my Autism Series.

If you haven’t read last week’s post, click here to read it. I spoke about life milestones and how these affect both neurotypicals and people on the Spectrum. I also highlighted the effects in another post (read it here).


1In this week’s post, I want to tackle a big topic: social communication and how this is worked out by people on the spectrum. This is a very big topic, and therefore I don’t expect to talk about everything in just one post.

If you have any suggestions about what I can add, any questions, or you want to guest post about this topic, do leave me a message.


The first thing to remember is that people on the Spectrum are like all of us in most respects.

We all need to eat, drink, shower, have meaningful activities and relationships. We all have needs, wants, preferences, favourite people and activities. We all have hormones – (((this is a whole other topic for another day, but an important one at that as it has been difficult to get people to understand that sexual needs are for everyone not just neurotypicals or those without disabilities of any kind. Why?)))

In spite of those similarities, there are some marked differences, one of them being social interaction and communication.

Their perception of the world is different to neurotypical ways of perceiving the world, and therefore the way they interact with the world is going to need to be different.


2Let me get a bit philosophical, authors such as Locke, talk about realism and how our perceptions are only mental representations of the actual object we are observing.

In this way, every single one of us has a different mental representation of the same object, which might be slightly different but in the end we all know we are talking about the same object, right?


Sometimes those on the Spectrum might get confused – are we both talking about the same object? What is it about this conversation about this object that is confusing me? Am I missing something that is being communicated – sarcasm, facial expression, tone of voice?

This might lead to what we often call “challenging behaviours”.

I would rather call them communications and coping mechanisms to what turns out to be a difficult situation for the person.

Trying to figure out whether someone is using sarcasm, making a particular facial expression to match their verbal communication, or saying something in a particular tone can be exhausting.

3Many people with Aspergers will have set rules that they’ve figured out through the years, to identify what is going on in a social interaction: “when someone crosses their arms it means that they are angry with me”, for example.

This could be true in most occasions, but what happens when the assumption is wrong and the person is just holding their arms together because they are cold?


I am finding it important in my sessions to normalise what is Aspergers/Autism behaviour and what is “being human” behaviour.

Normalising and giving alternatives like the one above to different situations, without shaking up their well-designed system of interactions, helps develop new skills and add to already existing ones.

What is OK to do in a social interaction and what is not, is a very subjective thing indeed. And therein lies the difficulty.

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This includes being able to ask questions about particular behaviours someone might be unsure of – “I see you’ve crossed your arms, are you ok?”

There might need to be some practising to get there, and some energy investment in this, but it might help with their future interactions in similar situations.


Someone on the Spectrum might expect a conversation to go one way, but being unable to control what the other person is saying might mean they are surprised by the response and might need to invest some time and energy in figuring out what they mean – facial expression, tone, sarcasm or not – and what the best response is in this case.

Providing a space to develop communication skills and question the need for them is important. Acquiring new skills through therapy or coaching might help gain better understanding of why we do what we do, why do we respond like we respond, and why we hide when we hide – this applies to both neurotypicals and people on the spectrum.


With my less-verbal or fully non-verbal clients, I find it important to really “listen” to the body language.

Being attuned to the subtle communications is vital and it improves my relationship with the person, and in turn allows them to access more of what they need and find fulfilling activities and interactions.

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They might realise they can trust me more because I am watching closely and responding to their cues.

I can then verbally express what I think they want, and keep showing different objects, activities, pictures or symbols until we definitely get to what the person really is communicating they want.

Sometimes I will get it wrong, and I will apologise for doing so, or for taking too long to get it.

This also happens in neurotypical to neurotypical interactions, but it’s enhanced by the lack of verbal input and other ways of communication used by the individual.

A quick eye gaze towards a favourite object, a particular sound in response to me asking whether they want a drink (or something else), is so important. It is how they get their needs met.

(Verbal) Neurotypicals might just need to say, “can you pass me that drink please” and that’s it. Quick and simple. We get our drink!

But getting that drink when you are non-verbal, maybe have limited ways to communicate, interact and move, amongst other things that might need to be taken into account here, might take a bit longer…


There’s a lot of food for thought here…So I am going to leave it there for this week.

Next week I want to talk about theory of mind and intense world theory, which helps understand even more the social struggles someone on the Spectrum might experience.

I hope this has been helpful. If you find anything that might need rephrasing, rewording or amending altogether, do let me know.

Would you like to add anything? Send me a message and let me know.


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Autism Spectrum Series – Life Milestones and their consequences

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Welcome to this week’s In Therapy post.

So far, I have written about topics that I feel will be helpful and informative to everyone in society.

1For the next few months, I have decided to start a series on topics that might be helpful to people on the Autism Spectrum and those around them.


The topics will be around issues that “mainstream” folk might also struggle with, so this will still apply to everyone, but I will be putting the emphasis on the added different situations that might creep up for those on the Spectrum.


I might not be able to tackle every individual situation that might arise – with that I mean that each person on the Spectrum will experience the same situation in a different way and might need a different way of working through it.

For example, loud music might be a problem for one individual but not for the other. So, having a noisy neighbour who plays loud music all the time might be Ok for the first person but might be causing all sorts of problems for the other. One might need some support in dealing with anxiety and stress of the noise, whilst the other might be blissfully unaware of the noise that’s going on.

Do let me know if there’s any particular situation that you’d want me to talk about in the series, and I’ll be happy to include it.


2This week I want to talk about a topic that is a peeve of mine as a member of society.

I have spoken about this before (read my post on the should, must and have to’s), and it’s something that I am passionate about challenging.

It causes more harm than good, in my opinion.

Especially to those of us who do not meet the stereotypical or the average lives that are expected from us.

The stereotypical or average lives usually include something like this:

Be born

Go to school

Go to university

Get a job (possibly for life, even if miserable!)

Get married

Have children

Retire

Die

Ok it’s very general and there might be some more or less in that list according to your individual culture and society, but this should look familiar to everyone to a certain extent.


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What happens when we don’t fit into that stereotype?

When we do something different like go the entrepreneurial route rather than the employee route?

What if we decide to not have children?

What if we never buy a house and move around the world often?

The list goes on…

Well that’s usually met with judgement and tut tut’s from our loved ones and others we might cross paths with.

Or it might be met with acceptance, well done if you’ve found those open minded people in your life!

This is just what us “neurotypicals” have to deal with.


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People on the Spectrum might have to deal with that and the added bonus of having to deal with difficulties as the one I describe above about the noise issue.

I say difficulties, let me correct myself and say differences.

Yes it’s difference not difficulty.

We all learn to adjust and deal with circumstances with the tools and abilities we have been given.

This is no different in someone with Autism.

It in fact becomes more important and part of everyday life.

Maybe someone on the spectrum will not be able to have a job that their neurotypical counterpart might have, but that doesn’t mean they are not a valued member of society.

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Could they have skills and abilities that gives back to society in a way that doesn’t meet the stereotypical working style?

Yes!

We just need to allow the space to develop this and not judge what we don’t understand.


There are other aspects of life, other than work, that need reviewing for both neurotypicals and people with Autism.

For people on the Spectrum and those of us around them, it might be even more pressing to challenge these society imposed life milestones, and allow for more flexibility and creativity in how things are done and how lives are lived.


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Acceptance is one step…

Acquiring knowledge and understanding is another…

Living and letting live, whatever it looks like for whomever we are talking about – neurotypical or autistic – is, in my opinion, the greater step.


Have you got something to add to what I’ve said so far? Do let me know and I will make sure I add it to the next post.

Would you like to guest post in this series? Write to me and we can arrange it!


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