Tuesday, February 23, 2016

5 principles for psychotherapists working with ASD

Just now, I viewed a video by Barry Prizant describing "5 Tips for Educators who Teach Autistic Students."  This inspired me to return to this blog after a multiyear hiatus and write up some principles from my work with clients ages 2 1/2 to 45 and my work training psychotherapists and other helping professionals.   It's a quick draft; tell me what you think.

 ASD principles for therapists

1.  Join the client where they are, and build from there.  General psychotherapy principle that is crucial in keeping the ASD client from being overwhelmed while also keeping them learning, developing, stretching.
If the child is nonverbal, conduct yourself nonverbally at first, first without engagement or stimulus, then doing some mirroring and invitation to mirror, creating communication through noise and movement even if the client’s actions are expressive, not communicative, at first. later adding some words (without doing simultaneous nonverbal communication at first), paired with meaning if the child does not have receptive language.
For the child speaking only in echolalia, use the echolalia as dialogue, striving to interpret functional echolalia when it happens, responding as if it were intentional and as if it was neurotypical speech, while feeding the child the lines that would have more effectively communicated to a neurotypical person. 
    For example, in a young child, tossing a child a soft ball high and low and then offering the child a choice of which phrase to echo to choose whether they want you to throw the ball high or low… even if they are actually just echoing the last phrase you said. This brings up an extension of this first principle:  “Building from there” may mean setting up situations where desired useful behaviors are likely to happen, then making those behaviors useful when they come close (the principle of successive approximations). 

2. Related to #1:  Start with accommodations, then add challenges.  This means: expect some discomfort if you expect change/development.  This is another principle of psychotherapy, related to physical therapy:  learn how to create comfort, but then realize that change will involve some discomfort, if the goal is to strengthen the client and help the client be more flexible, adaptive.  This means a middle ground between never wanting the child to experience any stress or challenge, and never wanting the child to have specially adjusted expectations or conditions. 

3.  Build a theory of mind ABOUT the child even more than IN the child.  
With a younger child, this mean helping parents realize that the nonsensical/nonfunctional use of “what is this toy going to do next?” (when only the child knows) which seems like the child’s theory of mind error, is really an attempt to strike up a conversation during play the way a neurotypical child might say, “guess what my toy is going to do next,” which by the way, like a lot of neurotypical behavior, also can be seen as nonsensical and nonfunctional and evidence of a theory of mind confusion.
This can also mean making, and explaining the implications of, the ASD diagnosis. 
For example, a family of an early 20’s “child” client, along with previous teachers and therapists, saw their child as defiant, conduct-disordered, obsessive-compulsive, inattentive, destructive impulsive (ADHD), unpredictably moody (bipolar), and above all determined to make their lives miserable and refuse to learn.  Making and explaining the diagnosis meant seeing that the child: doesn’t understand what is hurtful, may “experiment” to find out what works, has trouble using language and body awareness to understand and regulate their emotions, gets overwhelmed by certain stimuli and by social demands to process multiple simultaneous types of sensory input (processing facial expressions AND language AND memorized social rules).  This understanding made peace, and began a process of success that extended into the world of employment.

4.  Empower the client decide to what extent they want to try to “normalize” their behavior.  Some of the greatest teenage stress comes from adopting the expectation that they are supposed to develop a neurotypical-style set of friendships when it’s not really what they want.  This goal doesn’t mean letting anxiety make the decision about which goals to pursue; it means finding the child’s preferences and desires underneath the inhibiting anxieties and pressured social expectations.


5.  Help the client develop their own style of reaching those goals.  This can mean using visual memory rather than intuition to learn social skills.  For example:  A young adult woman with ASD wanted to want to fit in socially, and do so by memorizing social scripts and practicing facial expressions in a mirror.  A young man with ASD made a game of developing strategic social perception skills by learning to notice recurring patterns of behavior to predict what will come next and what response will work, much as one might learn to play poker not by reading body language but by seeing the meaning of certain betting patterns. 

There are many more potential principles and of course many specific strategies to describe, but these are the ones I find myself saying over and over again when talking to clinicians about helping clients and families navigating life on the autism spectra.  

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