Autism Spectrum Disorder and Psychotherapy

by Felicity Connolly

Introduction
Autism is a condition which is becoming more widely known in Ireland and around the world with the latest figures from the Center for Disease Control and Prevention (CDC) in the United States estimating that as many as one in 68 children in the US has ASD (Autism Spectrum Disorder: CDC, 2016). Debate continues as to whether this is due to increased rates of diagnosis or increased rates of occurrence. This question shall be left to others to address if they wish. The aetiology of ASD is also much debated but the reality is that much remains unknown about the how and why of autism. Some have pointed to attachment theory to explain ASD and yet, in writing on early development, Margaret Mahler observed children who seemed not to have the capacity to “utilize the mothering principle”, who despite the presence of a “mothering person”, were unable to enter into a nurturing relationship with mother and had either “autistic” or “symbiotic” defences and developmental difficulties (Mahler et al., 1975: 6-7). Attachment theory could be too blunt and judgemental an explanation for the complexities of ASD. Again, this question shall be left to others to address if they so wish. For the purposes of this article, the key point is that many people are affected by ASD and many people will have a friend or family member who is affected by this condition. Research suggests that people with ASD can experience particularly challenging levels of anxiety and depression (Gillott & Standen, 2007; Sokauskas & Gallagher, 2010).

I chose this subject for my final year diploma research project as I wanted to learn about the lived experience of ASD and share this learning with others in order to help facilitate positive psychotherapeutic experiences with clients with ASD. I am grateful to Micaela Connolly for her insight, time and encouragement in this endeavour. I will outline some recent research into the effectiveness of different types of therapy with clients with ASD. I will then suggest some potentially useful approaches to working with a client with ASD based on the content of a number of these publications. More importantly, I will emphasise that this therapy can be rooted in the core values of Humanistic and Integrative Psychotherapy. Psychotherapy is fundamentally based on trying to understand the inner world of the person who comes to you as client and helping the client feel understood. This is the ever-powerful experience of empathy. Feeling understood and understanding others is an area which might be very challenging in the life of someone with ASD and so could be all the more healing when experienced in a therapeutic relationship. I will conclude by outlining how my research into ASD can inform my therapeutic practice in general. There may be many clients who do not have a diagnosis of ASD but who nonetheless might benefit from the various approaches I will outline here. The word ‘spectrum’ is useful to highlight. Within the Autism spectrum there is huge variation in how the condition expresses itself from one person to another. Perhaps many of us could place some of our ways of being somewhere along the ASD spectrum.

What is ASD?
Autism Spectrum Disorder, or ASD, is the term used in the Diagnostic and Statistical Manual of Mental Disorders to describe a range of lifelong developmental disorders, including what was previously called Asperger syndrome (American Psychiatric Association, 2013). ASD occurs in all ethnic, racial and socioeconomic groups, with boys being statistically more likely to be affected than girls by a factor of four. The expression of ASD varies greatly from person to person. Some people with ASD have significant intellectual disabilities, including delays in language and cognitive development, while others have highly developed verbal and intellectual ability and lead independent lives. People with ASD tend to have persistent difficulties with social communication, social interaction and social imagination. A person with ASD may or may not have difficulties with motor coordination, emotional and behavioural issues, sensory issues, issues with attention and impulsivity, and psychiatric disorders (Connolly & Gersch, 2016). ‘Special interests’ can be a feature of ASD whereby a person may have an intense interest in a specific hobby or topic. Obsessive compulsive behaviour can also be associated with ASD and deviations from familiar routines can be difficult to bear (Gaus, 2011; Kiep et al., 2015).

Theory of mind
A widely accepted theory is that people with ASD tend to have difficulty with what is called ‘theory of mind’. Theory of mind is the ability to attribute mental states to oneself and to others. This means being able to identify what is happening in one’s own internal world at a given moment and being able to make educated guesses about what might be happening for another. This ability may be a vital part of what makes social communication and relating possible. It allows us to understand and predict our own reactions and behaviours and those of others (Frith & Happe, 1999; Happe, 2003). Without this ability, the world could be a frightening and unpredictable place where little makes sense. It is easy to see how rigid routines and patterns of behaviour could help oneself feel safer in such a world. Temple Grandin, an American professor of animal science who publicly shares her experiences of being on the autism spectrum, writes below about how she spent some of her time as a child.

I also liked to sit for hours humming to myself and twirling objects or dribbling sand through my hands at the beach. I remember studying the sand intently as if I was a scientist looking at a specimen under the microscope. I remember minutely observing how the sand flowed, or how long a jar lid would spin when propelled at different speeds.

(cited in Frith & Happe, 1999)

A difficulty in connecting with one’s internal world would have many consequences. The following is a quote from Gunilla Gerland, a Swedish author and lecturer who has written about growing up with Asperger syndrome.

My insensitivity to pain was by now as good as total…nothing hurt at all. And yet I felt – my actual feelings were not shut off – because when I was aware that I had injured myself somewhere, I could sense something, a non-pain, which branched out into my body from the place where the injury was. But the fact was, it didn’t hurt.

(cited in Frith & Happe, 1999)

Information processing
It has been said that people with ASD experience many of the issues outlined above as a result of differences in how they process information internally. They may process both social and non-social information in a very different way to the rest of the population. This may give rise to behaviours which seem unusual or different, which can be isolating, confusing and lead to feelings of rejection and hurt for the individual. When processing social information, a person with ASD may not easily recognise non-verbal cues such as facial expressions, gestures and body language. They may experience language and verbal communication in a very literal way, not recognising the subtle meanings behind figures of speech and metaphors. If they have difficulty with theory of mind, they may find it hard or impossible to imagine what another might be feeling or thinking. They may also have difficulty regulating their internal information feedback loops in terms of emotions, feelings and physical sensory stimuli (Gaus, 2011). Hypo- and hyper-sensitivity to stimuli such as heat, cold, light, sound and touch are frequently associated with ASD (Frith & Happe, 1999). In terms of non-social information processing, they may have difficulty with planning, organisation, goal-setting and cognitive flexibility (Gaus, 2011:51). This is not to say that people with ASD cannot overcome some of these difficulties and indeed use some of them to their unique advantages. Frith (1999) notes that some adults with ASD seem to develop a unique explicit version of theory of mind through sustained self-reflection. They may not begin life with an intuitive implicit awareness of their inner experience or the experience of others but they can develop these personal and social tools.

Can psychotherapy be helpful for someone with ASD?
Traditionally, psychotherapy was not viewed by mainstream healthcare as a viable therapeutic pathway for people with autism. Given the nature of heterogeneity within the population of people who have ASD, psychotherapy may not be possible in some cases and may be very useful in others. Difficulties with verbal communication and intellectual disability can present challenges to psychotherapeutic work. Flexibility, education and creativity on the part of the therapist might be particularly useful when working with clients with ASD, as indeed they might be when working with any client with an intellectual disability. People with ASD experience higher levels of anxiety than other population groups, with depression following up as the next most commonly reported emotional difficulty (Kiep et al., 2015). Psychotherapy is commonly used in the treatment of both anxiety and depression. Some of the life issues reported by adults with ASD include relationship difficulties, loneliness, employment dissatisfaction and anger. These issues can arise from the specific challenges of living with ASD and yet they overlap with some of the key issues that would be reported by any group of individuals for whom psychotherapy could be useful. Relationship difficulties can arise from the difficulties a person with ASD might have with social communication and interaction and this can lead to anxiety, loneliness and isolation and depression. Being unable to effectively communicate and express oneself as well as finding it hard to understand the behaviours of others can lead to frustration, hurt and anger. These difficulties with social relating can mean that maintaining employment is challenging and this can also create anxiety, frustration and depression (Gaus, 2011).

Research into Cognitive Behavioural Therapy
Currently, many sources of information about Autism recommend Cognitive Behavioural Therapy (CBT) as the therapy of choice for people with ASD who are experiencing anxiety, depression or other emotional difficulties. There have been many pieces of research published on the effectiveness of CBT with people with ASD, with some positive results. Many of these, however, were single case reports where a person with ASD attended CBT and reported some improvement in their wellbeing (Gaus, 2011). Several limitations which have been highlighted with the use of CBT and ASD include the fact that it reportedly took participants in studies a long time to grasp the concept of cognitive restructuring and it was questionable whether the gains through the therapy were of a lasting nature (Spek, 2013). It is apparent that while there has been some research into CBT and Autism, there is a distinct lack of large controlled studies with adults with ASD. It is also important to state that the presence of positive research for CBT and ASD does not give any clear indication that this is a more useful type of psychotherapy for adults with ASD than any other. There is simply a gap in our current knowledge in this field.

Research into Mindfulness-Based Therapy
I could find only two pieces of research into psychotherapy and ASD that were not related to CBT. These were two Dutch papers on mindfulness-based therapy (MBT; Kiep et al., 2015; Spek et al., 2013). Both studies involved a group of adult participants with ASD who attended several weeks of MBT group training plus a control group who did not. Both studies found that the groups who attended the MBT reported a significant decline in anxiety, depression, agoraphobia, somatisation, inadequacy in thinking and acting, distrust and interpersonal sensitivity, and sleeping problems. The effects were found to be of a lasting nature. The mindfulness training consisted of weekly group sessions where participants experienced guided meditations, body scans and were encouraged to share their experiences. The participants were also encouraged to practice daily guided meditations at home. Spek led one of these mindfulness-based studies and outlines the differences between this approach and CBT, and its potential advantages for therapy with people with ASD:

Thus, although both MBT and CBT both aim at reducing symptoms of depression and anxiety, the underlying mechanisms differ. In CBT, thoughts and feelings are identified and analyzed in order to examine whether they are beneficial and realistic, whereas, in MBT, analysis of the contents of thoughts and feelings is unnecessary. The acceptance without analysis is accomplished mainly by simple experiential exercises during which patients are learned [sic] to identify phenomena occurring in the present moment (e.g., bodily sensations, thoughts, feelings) and accept them just as they appear. In light of the deficits in theory of mind and communication of many patients with ASD, such emphasis on simple experiential exercises without the need to analyze and discuss thoughts seems highly suitable for these individuals.

(Spek et al., 2013:247)

Humanistic and Integrative Psychotherapy
It seems that this mindfulness-based approach of helping clients focus on and identify their experiences in the present moment with acceptance is very appropriate for working with people with ASD as they are likely to have particular difficulty in recognising their physical sensations and feelings and in navigating their own inner world. This focus on the present moment and on becoming aware of our sensations, feelings and reactions are some of the core aspects of Humanistic and Integrative Psychotherapy. The foundation of this type of psychotherapy is arguably the Rogerian mode of empathy, congruence and positive regard. The modelling and enactment of empathy and acceptance and the necessary theory of mind behind these could be very helpful for work with clients with ASD. Congruence and an ability to explicitly name what is happening in vivo in therapy would potentially be very useful when working with a client who may experience difficulty with the subtleties of everyday social communications. People with ASD often find it confusing when people so often in life don’t ‘say what they mean’. Unconditional positive regard is said by Rogers to be a necessary condition for human growth and personal development. This could be a rare and precious therapeutic experience for someone who feels different or isolated in life (Rogers, 1980).

What might help the psychotherapist facilitate a client with ASD?
My hope is that first and foremost, the preceding information will have given some insight into how a person with Autism experiences themselves and the world around them. This information can only serve to increase the understanding and empathy of a therapist working with a client with ASD. I will now outline some specific insights and approaches to therapy which may be useful when working with a client with ASD.

1. Body-oriented awareness
As described above, people with ASD can have particular difficulty with identifying their physical and emotional experiences. The importance of a focus on the body in psychotherapy has been discussed by many authors and it seems that increased awareness of one’s bodily experiences can help a client achieve insight, self-acceptance and personal growth (Smith, 1985). The positive results from studies into mindfulness-based therapy and ASD suggest that encouraging connection with inner experiences, feelings and bodily sensations in the present moment is a particularly useful approach for working with people with ASD.

2. Resistance?
In many forms of psychotherapy, therapists look for signs of ‘resistance’, where a client avoids facing his or her true feelings or reactions as a defence or way of protecting themselves. I would suggest that this might not be the most useful way to interpret the behaviour of a client with ASD. Many people with ASD have difficulty making eye contact. This may be because they do not understand or feel the significance of eye contact rather than being related to an avoidance of relating with the other. Likewise, they may have particular difficulty in connecting with and identifying their inner experiences. Such a client may not have developed the vocabulary for, or ability to, experience their feelings. As such, I’m not sure if they can be said to be resisting contact with what they have not learned to feel or describe due to the neurological basis of ASD.

3. Explicit communication and explanations
People with ASD can take verbal communications in a very literal way. This means that they might not understand a sarcastic joke and might find metaphors or figures of speech confusing. Some people with ASD might also find it difficult to perform exercises involving imagining something that is not really happening. If so, the therapist could make an effort to speak in more direct and explicit terms to avoid potential confusion and difficulties in the therapeutic relationship.

4. Boundaries and change
Establishing the nature and boundaries of the therapeutic relationship might be particularly important with a client with ASD. Again, explicit communication is key here. The client may not easily infer the expectations of others and may benefit from receiving a list of routine procedures, for example, regarding phone calls, financial obligations, when to arrive for a session, where to wait if they are early, when to knock and when not to. These specific details take the guesswork out of the therapeutic frame and so will likely reduce the client’s anxiety and reduce the likelihood of the client feeling shame for not knowing how to approach a situation. Change and transitions can be particularly difficult and anxiety-inducing for people with ASD. As such it seems very important that the therapeutic frame be subject to as little change as possible.

5. Visual aids
Many people with ASD process visual information more easily than audio input. Seeing a concept in writing might help such a client make more sense of it. There is some evidence that writing a journal can help people with ASD make more sense of their emotional experiences (Frith & Happe, 1999). Visual imagery is also useful in promoting insight into mental or feeling states. This leads me to my next point about a system called the Zones of Regulation which incorporates visually rich material.

6. Zones of Regulation
A person with ASD may have difficulty in identifying whether they are feeling sad or angry or anything at all. Leah Kuypers, an occupational therapist who works with children, devised a system called the ‘Zones of Regulation’ which may help such a person connect with their feeling states. This system uses charts featuring visual images of faces as well as descriptive behavioural and feeling words to help a person identify which emotional zone they are experiencing at a given moment. The system consists of four colour-coded zones with each colour corresponding with various feeling states. The blue zone applies when one feels sad, sick, tired, bored, is moving slowly or generally low in energy. The green zone applies when one is feeling happy, calm, feeling okay, focused, ready to learn or generally feeling well. The yellow zone applies when one is frustrated, worried, silly/ wiggly, excited, is experiencing some loss of control or is generally anxious. The red zone applies when one is angry, terrified, shouting, violent or feeling generally out of control. Kuypers is quick to point out that none of the zones is ‘bad’ and that each is a valid way of feeling. It is most useful as a means of promoting personal insight and increasing self-awareness in ways that work towards the strengths of a person with ASD – explicit description and visual cues. This system can help people who might find it hard to regulate themselves in stressful situations.

Kuypers also assigns colour-coded ‘traffic signs’ to each of the zones. For example, when a person feels ‘blue’ (sad, low in energy, tired) they might take this as a sign that they need to ‘rest’. This method could help many clients, with or without ASD, and even many therapists to carry out necessary self-care! (Kuypers & Winner, 2011).

7. Deep pressure and sensory breaks
Being aware of potential difficulties with hypo- and hyper-sensitivity to sensory stimuli could be useful in therapy with a client with ASD. There are many different techniques which can be used to help regulate sensory input. Some people with ASD need additional sensory stimulus to feel okay while others might need to find ways to reduce external stimuli. Some clients might find that they feel less anxious when they use a sensory technique such as deep pressure, self-massage or self- squeezing. Placing the palms together in front of the chest and pushing them together is one such method of deep pressure. Other methods which can be employed in daily life are forms of heavy muscle work such as using a punching bag, stretching, doing push-ups and most other forms of exercise. These techniques help deal with excess anxious energy and calm the nervous system (Brothers of Charity Southern Services, 2016).

How ASD can inform how I practice psychotherapy in general
I will take a number of insights away from my research in this area which can inform and enrich how I practice psychotherapy with any given client.

  1. This project has augmented my awareness of how different each client is and how differently they can experience the world and themselves in it.
  2. I see the importance of maintaining an openness, flexibility and adaptability around alternative approaches and techniques which might be useful for any given client.
  3. Deep pressure, self-massage and exercise might be useful tools for many people who have difficulty with anxiety.
  4. The visually rich ‘zones of regulation’ material could help many clients who have difficulty with connecting with their feelings. This is particularly true for people who learn and process information more effectively via visual methods.
  5. This research has also reaffirmed for me the importance of safe, clear boundaries and consistency in the therapeutic relationship. Change and uncertainty are particularly difficult for people with ASD but can create anxiety and be counterproductive in any client-therapist relationship.
  6. Once again, I am struck by the importance of awareness of bodily experience in therapy. When this connection with one’s body is functioning poorly, people can experience more distress and difficulty in life. This highlights the importance of mindfulness, meditation, and psychotherapy which focuses on the body and awareness in the present moment.

Felicity Connolly has just completed her final year of training for a Diploma in Integrative and Humanistic Psychotherapy with the Flatstone Institute. She is based in West Cork and can be contacted at felicityconnolly@gmail.com.

References:
American Psychiatric Association (2013). DSM-5 Autism Spectrum Disorder [Fact sheet]. Retrieved 08 September 2016 from http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf 40

Autism Spectrum Disorder fact sheet. (2016). Retrieved 05 April 2016 from http:// www.ninds.nih.gov/disorders/autism/detail_autism.htm#268313082

Brothers of Charity Southern Services. Information on sensory breaks [Fact sheet]. Acquired 19 January 2016.

Center for Disease Control and Prevention (2016). Data & statistics. Retrieved 29 April 2016 from http://www.cdc.gov/ncbddd/autism/data.html

Connolly, M., & Gersch, I. (2016). Experiences of parents whose children with autism spectrum disorder (ASD) are starting primary school. Educational Psychology in Practice, 32(3), 245-261. doi: 10.1080/02667363.2016.1169512.

Frith, U., & Happe, F. (1999). Theory of mind and self-consciousness: What is it like to be autistic? Mind and Language, 14(1), 82–89.

Gaus, V.L. (2011). Adult Asperger syndrome and the utility of cognitive-behavioral therapy. Journal of Contemporary Psychotherapy, 41(1), 47–56.

Gillott, A., & Standen, P. (2007). Levels of anxiety and sources of stress in adults with autism. Journal of Intellectual Disabilities, 11(4), 359–70.

Happe, F. (2003). Theory of Mind and the self. Annals of the New York Academy of Science, 1001, 134–144.

Kiep, M., Spek, A.A., & Hoeben, L. (2015). Mindfulness-Based therapy in adults with an Autism Spectrum Disorder: Do treatment effects last? Mindfulness, 6(3), 637–644.

Kuypers, L.M., & Winner, M.G. (2011). The Zones of Regulation: A curriculum designed to foster self-regulation and emotional control. San Jose, CA: Think Social Pub.

Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. New York: Basic Books

Rogers, C.R. (1980). A way of being. Boston: Houghton Mifflin.

Skokauskas, N. & Gallagher, L. (2010). Psychosis, affective disorders and anxiety in autistic spectrum disorder: Prevalence and nosological considerations. Psychopathology, 43(1), 8–16.

Smith, E.W.L. (1985). The body in psychotherapy. Jefferson: McFarland & Co.

Spek, A.A., van Ham, N.C., & Nyklíček, I. (2013). Mindfulness-based therapy in adults with an autism spectrum disorder: A randomized controlled trial. Research in Developmental Disabilities, 34(1), 246–253.

Additional Reading:
Counselling – NAS (2016). Retrieved 04 April 2016 from http://www.autism.org.uk/ about/strategies/counselling.aspx

Mental health and autism – NAS (2016). Retrieved 04 April 2016 from http://www. autism.org.uk/mentalhealth

Prizant, B.M. (2013). Questions on emotional regulation. Middletown Centre for Autism Research Bulletin, 8, 4–11.

Research Autism. (2016). Autism treatments. Retrieved 04 April 2016 from http:// researchautism.net/