A Spectrum of Solutions for Clients with Autism

Treatment for Adolescents and Adults

Rachel Bedard, Lorna Hecker

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000075687
• Edition: 1
• Topic: Psicología
• Subtopic: Trastornos del espectro autista

This book is a comprehensive resource to guide work with individuals on the autism spectrum. It reflects the true range of needs presented by individuals with autism, pulling together the most salient aspects of treatment with invaluable information from several disciplines synthesized to guide your work.

Divided into topical sections with chapters from three field experts in each, this book features contributions from therapists, educators, and medical doctors, as well as financial planners, health advocates, and innovators. The diverse disciplines and backgrounds of each author lend a different voice and perspective to each chapter, reflecting the continuum of care necessary when working with clientele on the autism spectrum, and that, for clients on the spectrum, one solution does not fit all.

For use by psychotherapists, counselors, applied behavioral analysts, occupational therapists, social workers, teachers, and more, this text presents readers with expertise from various contributing disciplines to give them a treatment resource that can inform andguide their daily work with clients on the autism spectrum.

Part I

Individually Focused Treatment

It is vital that therapists know how to engage clients on the autism spectrum and create an effective treatment plan. These clients are often driven to therapy, both figuratively and literally! Adolescents are often brought by their parents, sometimes with the expectation that the therapist will just meet one on one with the adolescent and the parent will be uninvolved, taking a needed break in the waiting room. Other parents, in a twist of developmental irony, will want to be actively part of the treatment team for their adult children. Adults may be referred by others who see them struggling, sometimes they self-refer, or they, too, may be brought to therapy by their aging parents. As a therapist, you need to be prepared to connect with and nurture whatever team shows up in your office.

In this part, three experts share their wisdom about individual therapy. You will see that the experts agree that anxiety management, mood management, and social communication development are primary goals, but how each professional engages the client varies. Further, it is clear that some treatment teams intentionally engage parents, while other treatment teams work more directly with the client in a one-on-one setting to build skills. No matter the approach, you will find each author advocates for respect for neurodiversity and crafting a unique, individualized plan of action for the client.

1 Working with Individuals on the Spectrum

Tony Attwood

Autism occurs in approximately one in 59 adolescents and adults (Centers for Disease Control, 2019). Diagnostic criteria imply that someone who has autism will need support and guidance in social communication and interaction, reducing restricted and repetitive patterns of behavior, and coping with sensory sensitivity. Autism is also associated with mood, eating, learning, and personality disorders (Attwood, 2006). While we have the formal diagnostic criteria for autism (American Psychiatric Association, 2013), I have my own description of autism. The term autism describes someone who has a different way of perceiving, thinking, learning, and relating and discovered interests that are more enjoyable than socializing. Unfortunately, people who have autism are a minority in a world of social zealots. Those on the autism spectrum can benefit from having a therapist who understands both the challenges brought by their neurodiversity, but also the challenges of their being marginalized by a neurotypical dominant majority.

What Are the Top Concerns When Diagnosed With Autism?

Anxiety

Teenagers and adults who are on the autism spectrum appear to be vulnerable to feeling anxious for much of their day, often experiencing extreme anxiety in anticipation of, or in response to, specific events, such as socializing, sensory experiences such as the sound of a hand dryer, making a mistake, or a change in expected routine. Research has confirmed that an anxiety disorder is the most common mental health problem for adolescents and adults who have autism, with prevalence figures ranging up to 84 percent (Mattila et al., 2010; Van Steensel, Bögels, & Perrin, 2011; White, Oswald, Ollendick, & Scahill, 2009). An Internet survey of over 300 adults with autism indicated that over 98 percent ranked anxiety as the greatest cause of stress in their daily lives, greater than the stress associated with making and keeping friendships and relationships, finding and maintaining employment, and coping with daily living skills (Attwood, Evans, & Lesko, 2014) Sometimes, the level of anxiety may be perceived as actually more disabling than the diagnostic characteristics of autism.

All types of anxiety disorders are more frequent in teenagers and adults with autism in comparison to the typical population (Van Steensel et al., 2011). An assessment of the circumstances associated with, or that create, heightened levels of anxiety for the person who has autism can indicate an intolerance of uncertainty (Neil, Choque Olsson, & Pellicano, 2016; Wigham, Rodgers, South, McConachie, & Freeston, 2015) and a fear of judgment, being targeted for bullying, teasing, rejection, and humiliation, fear of making a mistake, and aversive sensory experiences (Attwood, 2006).

Socializing with peers is perhaps the greatest source of anxiety. Anxiety can frequently be associated with specific social situations, such as those circumstances where there are no apparent or previously experienced social rules, or where the social codes or conventions are being deliberately broken by others.

Depression

There are many reasons why an adolescent or adult with autism may become depressed, including feelings of social isolation, loneliness, and not being respected or valued, as well as internalizing and believing past criticisms. Another reason is the exhaustion experienced due to socializing, trying to manage and often suppress emotions, especially anxiety, and coping with sensory sensitivity. The person is constantly alert and anxious, trying to endure perpetual anxiety with a deficit in emotional resilience and confidence. The mental effort of intellectually analyzing everyday interactions and experiences is draining, and mental energy depletion leads to thoughts and feelings of depression.

The frequent and high level of bullying and humiliation by peers (Maiano, Normand, Salvas, Moullec, & Aime, 2016) can lead adolescents and adults with autism to believe they are indeed defective, and this belief affects how they will perceive themselves and their experiences. There is a heightened sense of self-blame and pessimism, and increased anticipation of a lack of social and academic achievement (Sharma, Woolfson, & Hunter, 2014). Problems with executive function, resulting in a degree of disorganization, can lead to feelings of underachievement, particularly when juxtaposed to the person’s intellectual abilities. While typically developing teenagers and adults will have several close friends who can quickly and easily repair their emotions and provide reassurance and evidence that negative self-belief is not true, the isolation and lack of friendships of the person with autism can not only be a cause of depression, but also perpetuate the feelings.

Additional Concerns

Alexithymia

The term alexithymia describes the characteristic of having a diminished vocabulary of words to describe emotions; alexithymia includes struggling to identify one’s own emotions as well as the emotions of other people and is a characteristic consistently associated with autism (Berthoz & Hill, 2005; Hill, Berthoz, & Frith, 2004; Milosavljevic et al., 2016; Samson, Huber, & Gross, 2012). Research suggests that the person can identify having an increased level of emotional arousal, but has great difficulty labeling and eloquently describing the level of emotion (Ketelaars, Mol, Swaab, & van Rijn, 2016). When asked how they are feeling at a particular time, or during a particular event, a teenager or adult with autism may reply, “I don’t know,” which typically means, “I don’t know how to tell you.” The person may therefore have difficulty telling a therapist how anxious they feel and why they are anxious.

Clinical experience has indicated that those who have autism have a greater eloquence and precision in expressing thoughts and feelings through the arts rather than conversation (Attwood & Garnett, 2016). Art, music, and writing can be used to explore the person’s inner world of thoughts and emotions. A strategy that can be used in psychotherapy is to ask the person to create a play list of music with each song expressing the degree of emotion in the music or lyrics. Google Images can be used by asking the person to type a broad definition of a specific thought or feeling, and to select a number of images that eloquently and vividly express their thoughts and feelings. Other options include writing a poem or sending an email where we often observe greater insights through typing rather than talking. For example, if the client is an avid fan of a series of books such as the Harry Potter saga, we might ask them to select a passage or chapter that describes a particular thought or feeling; or we might ask them to choose a scene in the movies to describe their thoughts or feelings. Given the pull for musical or visual strengths, the multidisciplinary team could include an art and/or music therapist to aid with this expression.

Self-Identity

The sense of self of typical adolescents and adults is initially based on parental opinions and support, with the sense of self subsequently modified, and potentially reinforced or undermined by adolescent peers. Unfortunately, the sense of self of those with autism is often based on the criticisms and rejection of their adolescent peers rather than their compliments and acceptance. This can result in a propensity for an individual to self-blame and live in anticipation of failure and criticism. A negative self-identity can contribute to low self-esteem and depression. Clinically, when an adult who has autism is asked to “please describe to me who you are,” clients with autism often will either be genuinely unable to answer the question or will describe the self in terms of knowledge and expertise rather than social network or personality descriptions.

The Need for a “Village” (Multidisciplinary Team)

Given the myriad of concerns those with autism face, adolescents and adults who have autism will greatly benefit from a multidisciplinary team; it indeed takes a village. Clearly, there is need for psychotherapy in terms of high levels of anxiety or depression and encouraging a positive sense of self. There is also a need for guidance and support in reading non-verbal communication and social cues and conventions, making and keeping friendships, and working effectively in a team at work. These abilities have been studied by psychologists, who may provide programs to improve and enhance specific social skills. However, other disciplines can contribute to achieving greater social skills and social cohesion. A speech language pathologist can focus on the pragmatic aspects of language, especially the art of conversation and prosody. An occupational therapist can focus on coping with sensory sensitivity and any movement disorders associated with autism such as dyspraxia. A psychiatrist can be a valuable member of the team in terms of prescribing and reviewing medication for an anxiety disorder or depression.

Clinical Interventions

With individuals with autism, conventional cognitive behavioral therapy “tools” can be used, such as physical and relaxation activities, and changing perception and thinking to manage emotions. Additionally, in Western cultures, there is a growing recognition by clinicians and academics of the value of awareness activities such as yoga and meditation for increasing self-awareness, as well as promoting a general sense of well-being, and providing an antidote to anxiety. We now have yoga activities specifically developed for those with autism to use at home (Bolls, 2013; Hardy, 2014; Harris, 2018; Mitchell, 2014; Rubio, 2008). Mindfulness is also being used in school settings to regulate attention toward the present moment, to accept and observe emotions, and cultivate an attitude of openness and acceptance using imagery, meditation, and yoga (Conner & White, 2018; De Bruin, Blom, Smit, Van Steensel, & Bögels, 2015).

Therapists can also help clients by aiding in the development of social tools. The strategy is to find, and be with, a person or an animal that can help repair the mood. The social experience will need to be enjoyable and without the stress that can sometimes be associated with socializing, especially when the interaction involves more than one other person. Clinical experience and research have indicated that young adults who have autism have found it easier to relate to other people on the spectrum because of shared understanding and experiences in a relationship in which atypical social behavior and interests are normalized (Sosnowy, Silverman, Shattuck, & Garfield, 2018). The social “tool” may be the creation of a social network of like-minded individuals, perhaps members of an autism support group.

There are social experiences that can actually reduce anxiety, for example, being with someone who accurately “reads” the teenager or adult’s emotional state and intuitively knows what to say or do to reassure and calm them. Another social tool, in the broadest sense, is spending time with adoring pets who make the person feel safe. Pets are the best, non-judgmental listeners and can be more forgiving than humans.

My favorite interventions in psychotherapy are the Emotional Tool Box (Attwood, 2004, 2006; Attwood & Garnett, 2016; Scarpa, Wells, & Attwood, 2012) and Energy Accounting (Attwood & Garnett, 2016), and I regularly utilize them in my clinical practice. The Emotional Tool Box aids clients in replenishing themselves and alleviating anxiety and depressive symptoms. Maja Toudal, an individual with autism, originally created the concept of Energy Accounting to help her cope with her cycles of depression; it is a useful tool to help clients understand how to both guard and repl...