Art Therapy with Adults with Autism Spectrum Disorder

Beth Gonzalez-Dolginko

• Publisher: Jessica Kingsley Publishers
• Year: 2019
• ISBN:
  9781784509729
• Topic: Psychology
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

There is a distinct lack of art therapy literature on working with adults with autism spectrum disorders, and this book combats this dearth by looking at the theory and practice of working with this client group. With clinical case examples throughout, it provides ideas for practice and interventions for use in institutional and community settings. There is a useful focus on directives to help with specific concerns, for example college and job readiness, social skills, and adapting to independent living.

The book also includes information on ASD itself and gives advice on developmental and neurological considerations to take into account when working with this client group.

Part I

ADULTS WITH
AUTISM SPECTRUM
DISORDER

Introduction

Wow you’re really good at deciphering the life of Bert. Regarding the refrigerator… Yes Bert was very upset for several hours after that happened…because he thinks that he pushed it but it’s not leaking anymore. Yes he takes things very hard and does get angry. He’s been handling it quite a bit better the last few weeks and it lasts for a shorter time and he comes back and apologizes. He told me the other day that he squeezed his fists and it helped. Everything that you said is correct and you know him very well.

This email from a mother of one of my patients, who is an adult with autism spectrum disorder (ASD), lets me know that I am doing a good job. What I deciphered from snippets of repetitive phrases that Bert uttered in a pressured tone during his session was that he had gotten angry about something and become physical. I immediately made a contract with him that I sent to his Mom, with his permission. It stated that: he must never raise his fist to his Mom (he had not hit her but would shake his fist at her when angry); and he must not break anything when angry and should, instead, punch a pillow or couch. The squeezing of his fists, to which his Mom refers, is related to a relaxation exercise I had taught him to help him control his anxiety. We call it relaxation imagination, and he is incorporating it into his coping skills to reduce anxiety, stress, and angry outbursts.

As a therapist, one always wants to hear about successful treatment. But people with ASD may not always let you know that you are helping them. It may not be in their expressive repertoire. I often have to hear this from their parents or caregivers. Additionally, I determine success and progress by looking at their lives. If I can see that there is increased self-awareness, improved social skills, and better emotional and behavioral regulation, art therapy is helping them.

The literature is replete with research and information about children, from birth through school age, who have ASD. Yet these children grow up to be adults. There is an overall paucity of literature regarding adults with ASD. There is no significant literature, which I am able to find, about art therapy with adults with ASD. And as people with ASD age, they continue to have ASD and can continue to benefit from art therapy.

Whenever I teach or present on the topic of art therapy with adults with ASD, art therapists approach me telling me how hungry they are for information about this and feel alone out there in their work with adults with ASD. These art therapists work in a variety of settings, including small institutions, group homes, and day programs for adults with ASD.

This book addresses using art therapy with adults with ASD, through a social, emotional, behavioral, and cognitive description of adults with ASD, based on related social, emotional, behavioral, cognitive, developmental, neurological, and art therapy theory. Because adults with ASD present with layered and intersecting developmental stages, there is discussion of psychological devel-opmental theory, art developmental theory, and neurological implications, all with treatment suggestions and clinical snapshots. There is also a general discussion of cultural competence for art therapists and all mental health practitioners and suggestions for developing cultural competence when working with adults with ASD.

The second part of the book offers clinical art therapy group practice information about art therapy with adults with ASD in community settings, on behavioral health units, and in large institutions. It includes discussion of clinical treatment issues and supports awareness of developmental and neurological theories, as well as art therapy theory related to the effective treatment of people with ASD. Additional information addresses group format concepts, materials, supplies, and techniques, and includes illustrative case examples.

CHAPTER 1

Art Therapy Approaches and
Treatment Interventions
with Adults with ASD

Description of ASD and implications for treatment

ASD is classified in the DSM-5 (APA, 2014), which offers social, emotional, behavioral, and cognitive characteristics related to people with ASD. Those formerly identified as having Pervasive Developmental Disorder (PDD) or Asperger Syndrome (AS) are now identified with the ASD diagnosis, with notation regarding functioning level and severity (APA, 2014). A meta-analysis of current research (Richards et al., 2015) offers existing data examining genetics and metabolic profiles to better understand and explain the autism spectrum with its varying causes, symptoms, and presentation.

It is essential to consider social, emotional, behavioral, and cognitive aspects of ASD when developing an art therapy treatment plan for people with ASD. These characteristics persist as people with ASD mature, often becoming fixed in behavior and emotions. This is one reason why change and adjustment can be difficult for them and it needs to be considered when trying to implement art therapy treatment. Let’s look at some of these characteristics.

Social aspects of ASD

Developing a treatment intervention that considers the social needs of adults with ASD is important. People with ASD can present as disconnected from people and places around them. This could be as mild as appearing aloof or as severe as being completely withdrawn and nonverbal. People with ASD often have difficulties with social communication and social interaction, needing encouragement to engage in conversation. They may also have difficulty with verbal communication and an inability to process social cues and facial expressions related to emotions, which additionally interferes with conversation and social interaction.

A study by Howlin (2003) indicated that adult participants with ASD manifest pervasive restrictions in nonverbal communication with a high incidence of verbal communication deficits. Male subjects outnumbered female subjects in his study, which reflects the ASD community at large. However, it is worth noting that current literature explores reasons for this and indicates an increase in girls and women being diagnosed (Halladay et al., 2015). Participants had a high incidence of psychiatric comorbidities, including mood and anxiety disorders, but also attention deficit hyperactivity disorder (ADHD) and psychotic disorders, the frequency of which did not differ between males and females. A few of the participants in the Halladay et al. (2015) study led independent lives and very few had ever had a long-term relationship.

CLINICAL INTERVENTIONS AND SNAPSHOT

Group art therapy is a perfect place to support social communication and social interaction. As adults with ASD make art in a group art therapy session they talk, witness, and share. Participants who are otherwise quiet will often engage in spontaneous conversation with each other while making art. Sometimes friendships outside of the groups develop because participants develop their communication skills in the group and are better able to effectively engage in conversations and interactions, which form the basis of friendship. Participants realize during the course of the groups that they have things in common, another basis of friendship, including not always understanding another person’s emotions and having difficulty reading social and facial cues. Many longstanding friendships have emerged from my groups and a few short romances.

The art making gives participants some safe distance from eye contact and directly having to process social or facial cues. Often the symbols or images that emerge in the art give group participants something to discuss, such as a character from a graphic novel or a movie of interest to many of the participants. The art product offers adults with ASD an external representation of something they are thinking about or feeling. This distance helps participants to more deeply process feelings and experiences. Landy (1994) describes this concept as aesthetic distance.

Partner drawings and group sculpture are effective art therapy techniques to encourage social interaction and to process accompanying emotions. Of course, some adults with ASD may have sensory or perception impairments, which might cause them anxiety if they get too close to others. An art therapist must know each participant well so as to anticipate if the introduction of any intervention might cause any participant distress. Some adults with ASD are minimally verbal, and in art therapy groups, others who are more verbal seem to engage them and try to communicate with them.

In one of my groups, a new participant, Anne, 23, has very few words in her vocabulary and uses mostly American Sign Language (ASL) to communicate. Her Mom stayed with her during the group to help her facilitate communication. Other participants knew some ASL from their public education experiences and engaged her in interactions. Even though they might have their own social issues, they went out of their way to include her in the group. This effort at social communication demonstrated an acceptance and compassion that was obvious and probably the result of them all having been in public school as special education students. The special education system helps to nurture these valuable qualities in many people with ASD, and the group participants have learned and carried these qualities with them into adulthood.

Emotional aspects of ASD

Many adults with ASD have differences in the way they expe-rience emotions and many have difficulty expressing emotions. Consequently, adults with ASD may experience difficulty in developing, maintaining, and understanding relationships. Some may even lack interest in being with peers. They may have difficulty with reciprocity in an emotional exchange. Although this may be understood as a social concern, it has an emotional basis and impacts support systems. In fact, literature reflects that a lack of support systems results in poor outcomes regarding ASD in the areas of social independence and integration into the community at large (Howlin et al., 2015). Developing a treatment intervention that considers these emotional needs of adults with ASD is important.

People with ASD often suffer with anxiety. It may be a general emotional state, perhaps related to their awareness of being out of step with everyone around them (Battaglia, Detrick, and Fernandez, 2016). It could be extreme to the point of being a psychiatric diagnosis and needing medication. The anxiety may manifest as obsessions or fears and may interfere with certain functioning and processing of experiences. These obsessions or fears may be based on a lived experience or may be with an inanimate object, like an oil burner, and seem irrational. It is important for an art therapist to find out those fears or interests and build directives around them. For example, an art therapist could ask an individual to draw the object, if that does not cause too much anxiety. A discussion of the drawing could lead to some insight that could further progress in treatment and be used to develop an effective relaxation exercise to help reduce anxiety.

However, these directives may not necessarily lead to the root of the fear or anxiety and a subsequent road to resolution. For example, if someone has a fear of dogs, discussion might lead to them telling you of a time that they were chased and frightened by a dog. A therapist could then use cognitive-behavioral techniques, such as desensitization, to help someone diminish this fear and related anxiety. This is a fear based on logical cause and effect and can be treated. But fears of an inanimate object may very well be an irrational thought, often fixed in the psyche; therefore, there is no obvious solution. Directives bring the attachment or fear into a conversation in which a person may be encouraged to try certain drawing or relaxation strategies to reduce the associated fear or anxiety.

CLINICAL INTERVENTIONS AND SNAPSHOT

One individual patient with ASD with whom I worked, Marsha, 30, was obsessed with and frightened of jars that did not line up in size order on shelves or counters. I explored this, sensitively, in the art by asking Marsha to draw jars on counters and shelves in the way she would like to see them and tell me the story that went along with the drawing....