Individual Therapy

             Although access to psychiatric services is poor (Deudney, 2004) all types of psychiatric disorders are known to occur in people who have AS.  The most commonly reported disorders are ADHD in children and depression in adolescents and adults.  Anxiety disorders, OCD, phobias, movement disorders can also occur but true psychotic disorders are rare.  In fact, the most common cause of psychosis in autism is not schizophrenia but depression (Ghaziuddin, 2005). 

            As mentioned above, due to inexperienced practitioners, AS is often confused with a diagnosis of schizophrenia even though AS differences are present from birth and AS is not a state of progressive deterioration as with schizophrenia (Frith, 2003; Ghaziuddin, 2005).  A careful history ought to rule out at least some of these misdiagnoses. In one clinical study 66% (23 of 35) individuals were diagnosed with a psychiatric disorder as well as AS (Ghaziuddin, et al 1998).  The two most common diagnoses in this study were ADHD and depression.

 1.2.7  AS and Talking Therapies

          Human beings actively attribute ideas, intentions and feelings to the statements of other people as an inevitable part of two-way conversations (Firth 2003). Therapists, especially those driven by a particular theory of change, could not help but attribute intentions and interpretations to the words used by a person with autism, but this attribution can be dangerous when one member of the conversation can use words, intonation, and gestures in idiosyncratic ways, such as a person with AS would do.  This would automatically confound communication between the two, as they would not be working to the same understanding of the issues or the way forward.  An example of this from the author’s own practice occurred in a joint session between a psychiatrist, an individual with AS and the author.  The psychiatrist was attempting to get an overview of the person’s mental health and was asking questions regarding a recent walk in the park that this person had taken with his social worker.  The young man said he went to the park and did a little walking, but that he really didn’t feel like it.  He said he really didn’t feel well in his stomach like he had been poisoned or something. The psychiatrist immediately began questioning the person as regards ‘other delusional ideas’ because of the use of the word ‘poison’.  In another psychiatric interview, the individual answered affirmative to the question “Do you hear voices?” because he could hear the voice of the woman who lived in the flat below him.  In both these examples, it is the neuro-typical interpretations of the language used by people with ASD that lead to misdiagnoses and to the popular view that people with ASD are disabled or seriously mentally ill.

          People with AS sometimes lack the ability to converse in a to and fro manner, where what one person says builds upon what the other person says and vice versa.  The quality of their interactions may lack flexibility and spontaneity (Ghaziuddin, 2005).  These difficulties clearly impact on the success of talking therapies, especially traditional problem-focused work where the therapist is often rather inflexible in terms of the reasons ‘underneath’ the client’s present difficulties, the forms treatment may take and the goals that ought to be achieved (Johnstone, 1993).

          Typically, talking therapy is aimed at alleviating distress caused by the symptoms of autism (e.g. Hare and Paine, 1997; Attwood, 2004) but an increasing number of writers who have autism are suggesting that treatments are often aimed at normalising or ‘curing’ the autism because of the majority’s inability to accept different-ness.  Donna Williams (1996) categorises treatments in four ways; 1) those aimed at taking away the offending or disturbing symptoms; 2) those that try to understand what autism feels like; 3) those that try to understand the underlying causes of autistic symptoms; and 4) those that seek to cure autism and release the ‘normal’ person within (pp. 19-22).

          The mainstay of mental health treatment continues to be cognitive, behavioural, educational or most commonly a combination of all three types of work as summarised by Ghaziuddin (2005) who writes:

“All types of behavioural treatments incorporate elements of structure and consistency and are based on the premise that positive or desirable behaviours can be built and negative or undesirable behaviours eliminated.”  (p. 27).

 What is missing from this view of treatment is any indication about how to increase the level of effective communication between people with AS and their workers, suggestions as to how to help people with AS make progress towards their own goals or any suggestion as to who gets to decide which behaviours are ‘positive’ or ‘undesirable’.  The tacit implication of talking therapies therefore seems to be to help people with autism ‘get rid’ of their symptoms so as to ‘appear’ normal (Bogdashina, 2006). Unfortunately this professionally oriented approach predominates, not just for people with autism, but for all individuals with mental health needs.

          Cognitive Behavioural Therapy (Hare and Paine, 1997; Attwood, 2004, 2005), intensive behaviour therapy for prolonged periods of time (Lovaas, 1987), communication training, developing play skills, practising social interaction in a highly structured visually based programme (Schopler et al 1995) and social skills training (e.g. Gray and Garland, 1993; Attwood, 1998; Aarons and Gittens, 2000) have all been accepted standard approaches to work mainly with children who have autism.  These approaches have structure and active teaching of skills in common, which is somewhat different than talking therapies which are used for mental health reasons such as depression, anxiety, obsessive-compulsive behaviour and so on.

          Talking therapies include mainly CBT (Hare and Paine, 1997; Attwood, 2004, 2005). But according to some people with ASD, this approach is often confounded by a) a person’s limited facial expressions; b) a person’s difficulty understanding the intent of therapist’s behaviour and questions; c) lack of common language and experiences; d) idiosyncratic use of language, e) sensory hypo / hyper sensitivity that confuses incoming information and slows processing of information; f) the transience of words versus the concreteness of visual cues and g) involves a genuine difficulty noticing and naming emotions in self and others (Lawson, 1998).

          The author’s work using SFBT suggests that people with ASD do notice that professionals are not taking their wishes or hopes for the future into consideration, as one of the frequent comments clients make when asked about ‘what’s helped?’ in SFBT is that ‘therapist’s usually only half listen and then fill in the blanks with what they think is wrong, but the SF therapist does not do this’. 

          Assessing efficacy of talking therapy is difficult due to the usual reasons of getting sensitive measures of change or appropriate control groups, but also because what is said to go on in therapy is often different to what actually happens in therapy (Richer, 2001; White, 2003).

 1.2.8  Summary

            The underpinning philosophy of SFBT is about listening, co-creating, accepting client’s views and goals, centring on strengths and skills, noticing what has already worked for the person and talking about the person apart from the problem.  People with AS are indeed unique individuals with idiosyncratic ways of thinking, relating and speaking.  They wish to communicate and require flexibility on the part of others in order to maximise their chances to do so.  SFBT and AS seem, in broad terms, to be a good match.

            However SFBT involves all forms of communication, and additional guidance to therapists regarding the best ways to maximise the person’s participation and ability to benefit from therapy seems essential.  That this guidance should come directly from people with AS is consistent with the expert – expert stance of SFBT as well as with the author’s clinical work which shows that people with AS are indeed the best placed to identify things that work and do not work for them.

            As no work has yet been done in this area, the field was open as to where to begin learning from people with AS.  The notion of preferred futures is central to SFBT and is the basis upon which all work is done, so this seemed an important place to start with this research.

 References:

Aarons, M. and Gittens, T. (2000) Autism – a social skills approach.  Speech and language therapy for able children.  Communication, Spring, 18-19

Attwood, T. (1998) Asperger’s Syndrome: A Guide for Parents and Professionals.  London: Jessica Kingsley Publishers

Attwood, T. (2004) Exploring Feelings: Cognitive Behaviour Therapy to Manage Anxiety. Arlington, Texas: Future Horizons

Attwood, T. (2005) Modifications to Cognitive Behaviour Therapy to Accommodate the Unusual Cognitive Profile of People with Asperger’s Syndrome.  http://trainland.tripod, com/tony.a.htm [05/05] pp 1 – 6

Bogdashina, O. (2006) Theory of Mind and the Triad of Perspectives on Autism and Asperger Syndrome: A view from the Bridge.  London: Jessica Kingsley Publishers

Deudney, C. (2004) Mental Health in People with Autism and Asperger Syndrome: A Guide for Health Professional. London: National Autistic Society

Ghaziuddin, M., Weidmer-Mikhail, e. and Ghaziuddin, N. (1998) Co morbidity of Asperger syndrome: A preliminary report. Journal of Intellectual Disability Research, 42, 279 – 283

Frith, U. (2003) Autism: Explaining the Enigma. 2^nd Edition. Oxford: Blackwell Publishing

Ghaziuddin, M. (2005) Mental Health Aspects of Autism and Asperger Syndrome. London: Jessica Kingsley Publishers

Grey, C. and Garland, J. (1993) Social stories: improving responses of students with autism with accurate social information.  Focus on Autistic Behaviour,            I, (1) 1 – 11

Hare, D. and Paine, C. (1997) Developing cognitive behavioural treatments for people with Asperger’s Syndrome. Clinical Psychology Forum, 110, 5 –     8

Johnstone, L. (1993) Psychiatry: are we allowed to disagree? Clinical Psychology Forum, 56, 30 – 32

Lovaas, O. I. (1987) Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 565, 1, 3 – 9

 Richer, J. (2001) An ethological approach to autism. In J. Richer and S. Coates (eds) Autism: The Search for Coherence. London: Jessica Kingsley Publishers

Schopler, E., Mesibov, G., and Hearsey, K. (1995) Structured teaching in the TEACCH system. In E. Schopler and G. Mesibov (eds) Learning and Cognition in Autism. New York: Plenum Press

White, A. H. (2003) Cognitive behavioural therapy in children with autistic spectrum disorders.  In Bazian Ltd (ed) STEER: Succinct and Timely Evaluated Evidence Reviews, 4 (5). London: Bazian Ltd and Wessex Institute for Health Research & Development

            www.http://www.signpoststeer.org/

Williams, D. (1996) Autism: An Inside-Out Approach: An Innovative Look at the ‘Mechanics’ of ‘Autism’ and its Developmental ‘Cousins’.  London: Jessica Kingsley Publishers

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