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

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Hi, and welcome to 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). 

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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.

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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.

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 part 3), 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.

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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

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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.

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.

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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.

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Theory 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.

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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.

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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.

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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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