Counseling Adults with Autism

A Comprehensive Toolkit

Ali Cunningham Abbott

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429000683
• Edition: 1
• Topic: Psychologie
• Subtopic: Geschichte & Theorie in der Psychologie

Counseling Adults with Autism is a practical guide for counselors, psychologists, and other mental health professionals looking to improve their confidence and competence in counseling adults diagnosed with mild to moderate autism spectrum disorder (ASD). Organized into11 chapters based on key areas for guiding assessment and treatment planning for this population, this book highlights evidence-based practices and therapeutic interventions through case examples to demonstrate how assessment and treatment can be applied. Replete with insights from a variety of disciplinary approaches, this is a comprehensive and accessible resource for practitioners looking to support and empower clients struggling with social and behavioral challenges.

1 Presuming Competence and
Capability

One of the first steps in effectively treating clients is to understand how our approach influences the therapeutic relationship. The approach we take with clients is informed by our personal preferences, chosen theoretical orientation, mentors, research in the field, a variety of professional experiences, and systemic factors (Erford, 2018). This chapter will specifically review the importance of presuming that our clients diagnosed with autism (ASD) are competent and capable. But doesn’t this sound like a given? Absolutely, yes, it should be.

Yet, because of our historically entrenched ideas and inherent biases about ASD and other groups who have traditionally fallen into the “disability” category, it warrants an explicit review of why this is important (FitzGerald & Hurst, 2017). Unfortunately, like most people, mental health practitioners risk holding clients with autism to lower standards of achievement in many areas of their lives. Some may not think they can attain educational, work or relationship goals simply because of their ASD diagnosis (Artman & Daniels, 2012). Our inherent biases cannot be overlooked if we are to be at our best and fulfill our ethical obligations as practitioners to avoid doing harm or impose our own beliefs onto our clients (American Counseling Association, 2014). We have the potential to help significantly or harm depending on our own beliefs regarding autistic people. In one way this chapter serves as a reminder for us all that even though we may think we are presuming competence and capability in our clients, the work of monitoring our biases does not have a stopping point. We owe it to our clients, ourselves and our colleagues to refresh and reinvigorate our love for this work by learning ways to best acknowledge and address our biases.

But how do we move from simply taking on the mindset that our clients are competent and capable, to building this into our treatment approach? Guidelines and recommendations for taking action on how to build this mindset will be reviewed in this chapter. This starts with understanding the value of a strength-based approach and how to navigate the complicated clinical picture of splintered cognitive and behavioral skill sets. The chapter then reviews strategies that can help counselors best integrate these concepts into the treatment approach and provides a case example to highlight how this can be done in practice.

Starting with Strengths

In determining what actions to take in a competency and capability first approach to clients with ASD, this chapter will draw from best-practice, research-based recommendations for the general and ASD population. The first general recommendation is to assess and identify strengths from the start. How this can be approached specifically with ASD clients is discussed in how we can best identify both group and individual talents that will help guide treatment.

In order to implement this effectively we have to be intentional in the content and process of our initial contact with our clients. This can start simply and informally through initial screening and interviewing during which a counselor asks about their values, personal characteristics and aspects of themselves or their lives that they view as resources, and help to improve their mental health. Exploring both internal and external resources will be an essential first step to starting with strengths. It’s amazing to witness the surprising encounter this affords clients who are used to starting and engaging in treatment that is typically problem-focused. It is in these clinical moments, that we’re reminded about the importance of checking-in with ourselves and our colleagues so that we’re delivering the best quality of care.

When considering how mental health professionals can deliver best-practices in care, it is critical to keep in mind that diversity among people diagnosed with autism is just as varied as with any other group of people. Because of this, each client should be treated based on individual experiences, strengths, and challenges. Acknowledging this at the outset of approaching all clients is helpful in order to avoid overgeneralizing or committing the common error of making assumptions about one person based on their association with a group (Sue & Sue, 2016). Therefore, acknowledging individual differences and unique abilities from the start of building the therapeutic relationship is key to success. But in understanding the tripartite development of personal identity on individual, group, and universal levels counselors go a step beyond that to understand commonalities across unique individuals (Sue et al., 2016). Therefore, an awareness of group similarities and characteristics that aid in our understanding of our clients is also important.

The neurodiversity movement is a cultural phenomenon that has shifted the neurological disability paradigm to a humanistic, strengths-based view on people diagnosed with a variety of conditions (Elder-Robison, 2017). As with many grassroots, cultural movements this one began and continues on because of the work of adults with neurodevelopmental and neurocognitive disorders themselves. Within this movement, treating ASD adults and children as a cultural group, much like those of minority race, ethnicity, or gender status, is an approach that honors and respects their experiences as a group that has been marginalized and discriminated against.

Yet the counseling profession has identified in research and clinical experience the importance of acknowledging the complexities of marginalized groups (Sue & Sue, 2016). This is because many within these groups also hold privilege in certain areas that are vital to surviving and thriving. For individuals with autism, their privileges and strengths lie in many areas. Some examples are an incredible capacity for memorization or an ability to spend long periods of time attending to detail on specialized topics and skills. The criteria that makes them eligible for the disorder can become an asset or advantage when cultivated successfully.

Another factor of ASD privilege is that, often, the skills they embody are ones that non-ASD adults find uncomfortable, difficult, or even impossible to acquire. This creates a unique opportunity for people with autism to create a niche for themselves in different domains, including educational settings, the workplace, and social groups. For example, people with autism can be particularly skilled in different technological domains. Areas of the world in which prevalence rates of autism are above the norm, such as Silicon Valley – the technology hub of California – could be a result of a cluster of people with autism or the broad autism phenotype (BAP) finding a niche and succeeding in this industry (Van Meter et al., 2010).

Even though each person’s strengths should be assessed and identified individually, it’s helpful to have an understanding of several identified group strengths (Sue & Sue, 2016). These can serve as a foundation in guiding initial steps in assessment, from written, intake form questions to interview, screening questions used in the beginning stages of treatment. These strengths include but are not limited to those given in Table 1.1.

Early identification of the unique strengths exemplified by clients diagnosed with ASD is part of our responsibility as counselors and mental health professionals. Missing the opportunity to identify and cultivate these will

Table 1.1 Group level strengths of individuals diagnosed with autism

Identified strengths	Source
Tendency to be investigative and conventional in approach to work tasks	Lorenz and Heinitz (2014)
Creative, resilient and able to find meaning in life	Wehmeyer (2015)
Detail-oriented, specialized skills in particular area(s), ability to learn or study deeply	National Autistic Society (2016)
Logical in decision-making, independent thinkers, strong visual memory and processing skills	National Autistic Society (2016)
Direct communication skills; loyal, honest and non-judgmental	National Autistic Society (2016)

Sources: this list comprises a collection of common strengths as identified in the autism research, disability literature, and by professional organizations.

likely lead to an ineffective approach, therapeutic relationship and even stagnation in treatment progress. The strengths-based perspective that counselors highlight as part of our professional identity aligns well with this recommendation. It is vital for us to integrate this part of our training into our clinical view and approach in working with ASD adults (Grothaus, McAuliffe, & Craigen, 2012).

From Self-Efficacy to Self-Determination

Amongst the most important reasons that a strength-based focus is successful in the area of adult outcomes are self-awareness, self-efficacy, self-advocacy, and self-determination. Self-awareness is the ability to observe and know one’s internal states and characteristics (Goleman, 2005). This at the core of identifying strengths and tailoring treatment for achieving positive outcomes. It is essential to accurately assess and identify the ASD client’s strengths and challenges to improve quality of life outcomes (Mason et al., 2018). In clients for whom self-awareness is impaired, they may not have a clear picture of their own attributes, this will be one of the first steps in counseling. This is helpful to introduce by first focusing on one’s own strengths and continuing this work by exploring ways that clients can also become aware of their potential for growth. For those who demonstrate higher levels of self-awareness, repeating, emphasizing, and learning how to build on these strengths will be a goal in therapy.

Self-efficacy is the belief one has about one’s ability to accomplish or execute a task successfully (Bandura, 1977). A person’s measure of self-efficacy often reflects different levels of confidence and capability depending on the context. Among a small sample of college students with ASD, most reported confidence in a few features of self-efficacy, including getting information and other people to listen (Shattuck et al., 2014). But fewer than half of these same students reported being able to “handle most things that come their way”, a higher-level self-efficacy skill. Finally, those who identified racially as white and those who had better communication skills reported the highest self-efficacy. Racial minorities in college settings have long faced challenges in getting their needs met in higher education, which seems to be reflected in these results on self-efficacy among autistic students (Sue & Sue, 2016). Self-efficacy is a cognitive determinant that leads to exerting oneself, attaining goals and making decisions and should be a focus of intervention for adults with ASD. It could have far reaching effects in getting basic needs met and is viewed as the first step towards self-advocacy.

Self-advocacy is a person’s ability to speak up, stand-up for or represent oneself (Adreon & Durocher, 2007). Without the acknowledgment of one’s strengths and capabilities, taking action to effectively represent one’s views or interests is a challenge. When a person with ASD is able to self-advocate for accommodations and disclose their needs, this leads to better academic, employment and relationship outcomes (Shore, 2004). By focusing on strengths and taking action to build them, adults with autism can get their needs met in relationships, at work, and in the community. Without self-advocacy these possibilities are limited.

One of the best outcomes of counseling is when a client gains the self-advocacy skills of taking a stand, making a request and achieving their desired outcomes. Exploring the options from full to partial self-disclosure can open up the client’s understanding of how to inform others of their needs. Full self-disclosure usually involves sharing a lot of details about one’s diagnoses and medical history with accompanying paperwork in some circumstances (Shore, 2004). This kind of self-disclosure may occur in a workplace or formal setting in which accommodations are legally mandated. Partial self-disclosure is more limited in the amount of information shared and focuses on sharing characteristics about oneself that are important to know in order to get along well with others (Shore, 2004). This approach can be a good fit for clients who either reject their diagnosis or prefer to share more privately or generally about themselves. If a client can learn to disclose in a way that they are comfortable with, then their potential for sustaining a job, romantic partner or friends improves.

Self-determination is our natural ability to motivate oneself to behave in healthy and effective ways (Ryan & Deci, 2017). It allows people to be the cause of their own actions and freely make choices to meet their goals. Once a person experiences self-efficacy and successfully advocates for their needs, self-determination is the final step in building self-competence. Self-determination allows a person to be the change agent in the process of believing they are able to achieve and communicating those abilities (Wehmeyer, 2015). Therefore, the importance for building self-awareness, self-efficacy, self-advocacy, and self-determination will resonate throughout this guide.

In order to best understand our client’s level of competence and capability in different domains, I will highlight the cognitive processes and behavioral components involved in a variety of ASD presentations. First let us review common schema presentations that lead an adult with ASD to demonstrate different levels of competence and capability. From there, we’ll review the behavioral aspects of these clients that are commonly observed, which will help inform an effective way to approach and form a therapeutic alliance with them.

Cognitive Considerations

Adults with ASD have many years of childhood and adolescent experiences that help shape their cognitive processes. Depending on what occurred during their formative years, including family life, parenting dynamics, experiences in the educational system, and peer relationships, the manner in which they see themselves fitting into adulthood and how others will treat them have a significant influence. As it pertains to one’s cognitive competence and capability, it will be helpful to explore the connection between schema dynamics and worldview.

Schema dynamics describe a triadic cognitive process including one’s interpretation of self, others and the world. These schema dynamics are often connected to a person’s worldview. Worldviews are comprised of one’s reliance on internal or external loci of control and responsibility (Sue & Sue, 2016). This generally translates to how a person attributes responsibility and control in their lives, either to their own doing or factors outside themselves. Due to myriad factors, the results of schema dynamics and worldview of a client diagnosed with ASD present in a wide range.

On one end of this range are those who are self-assured, content, and have an exceedingly positive view of themselves and their fit in the world. Their experience during childhood likely involved supportive family members and effective parenting dynamics, academic success and relatively conflict-free experiences with peers. For individuals with these experiences they view themselves as in control and competent, others as helpful, supportive, and trustworthy and the world as a safe, trusting place. This resulting schema sounds like the best possible outcome. Yet, when amplified to an extreme this can lead to problems.

The results of this schema dynamic could lead an autistic adult to be overly trusting of others and be taken advantage of or have difficulty tolerating discomfort if they haven’t had experiences that expose them to challenges with peers or in achievement-based settings such as school and work. It can also result in a scenario in which the adult views themselves as more independent than they are and, in some cases, entitled. They may often view others logically and with a purpose as resources who either help or hinder their ability to get what th...