- 21 June 2017
- Posted in: Healthcare
Elaine Nicholson sets out some best practice guidelines for working with clients with Asperger syndrome.
My personal understanding of counselling methods has been very much shaped by the master’s thesis that I wrote in 2012. The title of the thesis was ‘An evaluation of lives that have become adversely affected by the experience of Asperger syndrome’. It was based upon a study of seven counselling clients of the Action for Asperger’s (AfA) charity, an autism specialist counselling charity that I founded in 2008. My research highlighted that Asperger syndrome individuals were squeezing themselves into therapeutic frameworks that did not wholly beﬁt their neurological make-up. The research showed that this practice of therapeutic ﬁtting was damaging. My quest was to learn about what works in counselling for autistic individuals and to conﬁgure future counselling practice accordingly. This article summarises my ﬁndings and highlights ways to enhance and improve the counselling experience for autistic individuals of all ages. It addresses some of the common pitfalls that counsellors often face when counselling clients with Asperger syndrome. Please note that, for the purposes of this article, I use the words ‘Asperger’s’, ‘autistic’, ‘autist’ and ‘autism’ interchangeably. Asperger syndrome is a pervasive developmental disorder that is on the autism spectrum. Although this condition is expressed differently in each person, it is characterised by qualitative impairments in social communication and social interaction, and stereotyped patterns of behaviour, including restricted interests and/or rigid adhesion to routines. These impairments cause signiﬁcant difficulties in important areas of functioning across a variety of settings, including vocational success, friendships and romantic relationships.
Individuals with Asperger syndrome have an IQ that is within the range of average to above average intelligence and are without cognitive or language retardation (1,2).
Asperger syndrome individuals are particularly good at breaking down problems using intellectual analysis(3). It might therefore be assumed that cognitive behavioural therapy (CBT) would be a good ﬁt for them. However, the area in which CBT often fails autists is the requirement to complete homework tasks, such as keeping diaries and schedules. The reason for this is that all autistic individuals have an inherently weak executive function (4). Executive function concerns an individual’s ability to manage, prioritise, time manage, execute and multitask. If I suggest homework to an autistic client, I risk losing them completely. Jason, an Asperger’s adult, received cognitive behavioural therapy in a hospital setting, and found his experience useful in providing some social skills training. However, he found keeping thought diaries an ‘artiﬁcial and added burden’. Jason also mentioned the goal-setting aspect of his therapy, and suggested that this overshadowed the ‘mental/ emotional’ issues concerning Asperger syndrome, which he considered he was ‘…only beginning to learn about’. Counsellors should therefore not feel that cognitive behavioural therapy is the only treatment option for autistic individuals, and should be prepared to explore other options. The model that is used by our charity has its roots in cognitive behavioural therapy and person-centred therapy but, importantly, also includes academic and/or experiential knowledge of autism and Asperger syndrome, along with awareness of sensory processing issues that pertain to the autistic condition. It is the inclusion of this other knowledge about autism and sensory processing that makes what our charity offers so unique.
Communication Style of the Counsellor
Attwood (2) asserts that Asperger syndrome individuals ﬁnd it difficult to understand and express their inner thoughts. He refers to a comment made by Liane Holliday Willey, an Asperger’s female, who states that ‘some of us never get to the point where we can look inward and explain outward’.(5) Ian, an Asperger syndrome adult who attended therapy with our charity, reported that the AfA model ‘doesn’t overanalyse the individual’s experience and thereby devalue their experience’, perhaps suggesting that the style is easier on the mind than other therapeutic interventions. He also commented that the discussion between counsellor and client is not ‘over-professionalised’ and that such an approach to counselling is helpful because it saves the client from feeling alienated or undermined. My research informed me that clients value you and what you have to say if, as a counsellor, you can show an understanding that goes beyond information that is gleaned from books. This is also particularly true for parents of autistic individuals. It is usual for parents to spend countless hours sitting in a state of shame in front of a school or college head teacher’s desk, attempting to deﬁne their child’s special needs, only to leave the room feeling unheard and swamped in bad feeling. Disclosure on the part of the counsellor can be healthy in this context, even though in traditional therapy, personal disclosure to the client is not encouraged, on the basis that it ‘takes away’ from what the client has to say. So, if you are a counsellor and/or an emotional support worker working with Asperger syndrome individuals, and you are also a parent of an Asperger’s child, it is perhaps worth mentioning it because it adds to, rather than takes away from, the counselling process.
The number of counselling sessions on offer to Asperger’s clients is of vital importance. Most clients with Asperger syndrome who I have come across, of all ages, have reported being offered a limited number of counselling sessions, usually six. Session quota limitation is driven primarily by restricted budgets and the belief that, in those six sessions, individuals can be taught skills and techniques that they will be able to use in the ensuing months and years as they encounter new difficulties. Remembering skills and techniques is ﬁne if an individual’s amygdala functions on an even keel, but if the autist is in ‘ﬂight or ﬁght’ mode, their ability to recall such strategies will be impaired due to anxiety. Autistic individuals should ideally have access to a cradle-to-grave counselling service because autism is not going to go away. At AfA, we stipulate to our clients from the outset: ‘Once under the wing, always under the wing.’ I explain in literal terms what this adage means, namely that the provision of counselling care from AfA is unlimited from the ﬁrst contact. Some professionals might consider that, by making such an offer, demand for appointments would then be exorbitant and might exceed supply, but this is not so. Clients understand that there is no need to hunger for something that is always going to be available to you. Another time consideration is the length of sessions. The autistic thinker’s cognitive process appears ‘busy’ compared to the neurotypical thinker. The AfA counselling method allows for a slightly longer counselling time per autistic client than the commonly accepted 50 minutes. This extended time period allows for cognitive ﬂexibility and for theory of mind deﬁcits, such as the ‘mind blindness’ theory.6 The mind blindness theory refers to what is known as an inability to put oneself in another person’s shoes, in other words to empathise, sympathise or associate. Alexithymia, a feeling of remoteness to words which describe mental states, can be inherent in the Asperger syndrome personality,(2) and may also interfere with the counselling process. By affording a longer time period than is usual in counselling, allowance is made for the individual’s theory of mind deﬁcit and potential alexythymic condition, enabling a less hurried and less overwhelming counselling experience for the Asperger syndrome client. Autistic individuals struggle to cope with change; it is a frightening concept for them. As therapists, we owe it to our Asperger’s clients to teach them that life and living can often be unpredictable, but that they can still remain held and safe in the therapeutic alliance. This is the reason why we keep the appointments ﬂuid and ask at the end of each session: ‘When would you next like to be seen? Perhaps in three weeks or one week? Would you prefer a morning or afternoon session?’ Many autists suffer poor sleep patterns. Consequently, a 9am appointment will not work for the individual who has been awake for most of the night, as they will struggle to engage in the session. Asperger’s individuals are usually very aware of their body clock’s best time and so counselling should be geared towards this.
Attwood (2) suggests engaging in a therapeutic ‘conversation’ with the client, using technology, so as to relax the client and gain greater insight into their inner world. The AfA counselling model offers clients the opportunity to email their thoughts, worries and concerns to their counsellor at any time of the day or night. This provides a vital ‘holding’(7) (comfort) facility for the worried client.
“Autistic individuals struggle to cope with change; it is a frightening concept to them. As therapists, we owe it to our Asperger’s clients to teach them that life and living can often be unpredictable, but that they can still remain held and safe in the therapeutic alliance”
The successful provision of a holding environment is of prime importance when counselling individuals with Asperger syndrome and other autism variants. Texting and social media private messages are also useful tools that help the autistic client to feel held. This idea may create alarm for some counsellors who are used to counselling neurotypical clients and who may perceive this as risqué practice. However, these methods of communicating have been found to work well for those on the autism spectrum. I know of many autistic individuals who use social media as their communication aid. Without it, they would not communicate at all. By offering a communication portal such as this, the message is sent out that one is being held, albeit at a distance. Rules of use, however, need to be made clear to the client. Video-calling services, such as Skype and Facetime, work particularly well if there is distance, either geographically or in the ability to connect. These counselling methods have enabled our charity to undertake work on a worldwide basis. They have also enabled us to reach out to some clients who, because of their autism, might be unreachable face to face. It is not uncommon for me to ‘Skype’ a client with only him/her seeing my face, but with me not seeing their face on the screen. Autistic individuals struggle with eye contact (2), experiencing it as a disconcerting form of social exchange. Many adult autists will have experienced criticism or complaints for their lack of social competence in this area. People on the autism spectrum crave understanding and acceptance. However, if the counsellor demands eye contact, this can engender a feeling in the client of not wanting to engage with the counsellor. Susan, an Asperger syndrome adult, told me, ‘I had many experiences in traditional counselling where I became stressed and then would struggle to engage. The counsellor would want me to look at her, and I physically couldn’t, or I might be able to manage to look up brieﬂy, but not for a prolonged period of time.’ By allowing a one-sided video call, a clear message is conveyed that the client’s inability to communicate via the language of the eyes is understood as a feature of their autism, and is not misread as communication avoidance.
Autistic individuals lack the ability to adjust to sensory experiences that other people accept as normal. However, if sensory needs are accommodated, problem behaviours become less of an issue (8). It is important that the counsellor is cognisant of the autist’s sensory issues in the counselling space. All counselling rooms at AfA are also sensory therapy rooms and contain a wide variety of soothing sensory therapy equipment. All rooms also have blackout blinds. Many autistic individuals are sensitive to light and may attend their counselling session either squinting from the bright outside light or wearing dark glasses, a baseball cap or a ‘hoodie’. This is the counsellor’s ﬁrst clue that the client might want the blinds closed, with low-level lighting used during their session. In one of our counselling rooms, we have an adult-sized dark den. The counsellor sits outside and the client has the option of using the den. The smallness and darkness of the space usually reduce ‘ﬁght or ﬂight’ anxiety within a very short space of time. It is important for the counsellor to ensure that there are no strong smells in the counselling space; for example, the counsellor should not wear colognes while counselling. It is also advisable for the counsellor to enquire about any smells that the client may dislike. For example, one young client of mine cannot stand the smell of cheese and onion crisps. The aroma makes him heave and vomit, and if I had them for my lunch, he would detect them and his afternoon counselling session would be over before it could start. Asperger syndrome individuals also tend to be highly sensitive to sound. If outside noise can be heard from within the counselling space, I might ask a client if they would like to wear some earphones that help to reduce white noise, but that do not take away voice sounds, so as to help them with their concentration (Bose QC 15 earphones are particularly good in this regard). Autistic clients also tend to be sensitive to voice intonation, so I keep the tone of my voice gentle and low throughout the session. AfA counselling spaces have coffee tables that have a box of ‘ﬁddle items’ on them. The ﬁddle items help engagement and mainly consist of small objects that can be manipulated, for example Magnetix or a Rubik’s cube. These aid concentration by assisting the client’s proprioceptive senses and removing the need for direct eye contact.
“Autistic individuals should ideally have access to a cradle-to-grave counselling service because autism is not going to go away”
There are many sensory goods on the market that can appeal to the vestibular and proprioceptive senses of an autistic individual. We have many different products that we use, including lighted walkways (walk and talk), inﬁnity tunnels and swings. In the words of Stephanie, another Asperger syndrome adult: ‘You can sit wrapped up in a weighted blanket because the pressure often helps, and enables people with autism to feel safe and secure, which is a big thing. You can put your feet up and relax on a sofa or a beanbag, because posture for autists is also a big thing, in that they may struggle to get comfortable in the chairs that are used in traditional counselling settings, which again, may impact on their ability to engage with the counsellor.’
It is very common for people with Asperger’s to have a special interest. Whatever the Asperger’s client’s special interest is, it is important to weave it into counselling communications, in order to encourage client engagement. For example, you might ask, ‘How would Pikachu (Pokémon) have dealt with this problem?’ or ‘What would this look like in a superhero movie?’ Play Scrabble with a Scrabble enthusiast and observe the words chosen; they can be highly illuminating. For example, when a boy who liked Scrabble selected the word ‘goad’ during a session, it led to his admission that bullies at school had been asking him to undertake ‘tasks’ that were meant to gain him some popularity. Communication, however elicited, is of vital importance to the person for whom communication is an inherent difficulty.
Be mindful of the fact that what works for neurotypicals does not work for Asperger syndrome individuals. For example, counselling work that encompasses ‘empowerment’ concepts, might lead to unwanted outcomes in the Asperger’s-affected client. I once knew of a counsellor who had built up an Asperger syndrome client’s sense of self so much that, rather than enabling him to ﬁt in better with the mainly neurologically typical society in which he was living, it isolated him further by heightening his inherent narcissistic qualities. He was consequently perceived as dreadfully narcissistic, bombastic and arrogant by those with whom he engaged, making him even more isolated. Beware of interpreting according to neurologically typical belief systems. Years ago, I often felt misunderstood by my personal therapist and frequently felt frustrated at trying to get her to see the ‘elephant in the room’, namely Asperger syndrome. Until a counsellor has gained a great deal of experience in working with this client group, counselling supervision by an expert in autism is essential and should be used to inform their work at each stage of the counselling process. Autistic clients often want to know, ‘Is my thinking to do with poor mental health issues or is it to do with autism?’ It would be incorrect to assume that, just because a person has autism, they suffer from poor mental health. It is important that the counsellor is cognisant of autism, and uses their knowledge of theory of mind, central coherence and executive functioning to inform their understanding of the behaviour and communication style of the autistic individual. Finally, it is vital to remember that not all autists are the same. If you have only met one person with autism, that is not tantamount to experience. I have counselled in excess of 1,500 individuals with autism, aged from three to 80 plus years of age, and with every person I encounter, I learn something new about autism. This is not only important to the future provision of autism-specialist counselling, but also for the continued personal growth and development of both the counsellor and the client.
1 Wing L. The relationship between Asperger’s syndrome and Kanner’s autism. In Frith U (ed). Autism and Asperger syndrome. New York: Cambridge University Press; 1991 (pp93–121).
2 Attwood T. The complete guide to Asperger’s syndrome. London: Kingsley; 2007.
3 Sofronoff K. Counselling adolescents. In Baker LJ (ed). Asperger’s syndrome: intervening in schools, clinics, and communities. Mahwah, NJ: Lawrence Erlbaum Associates Incorporated; 2004 (pp135–153).
4 Baron-Cohen S. Autism: a speciﬁc cognitive disorder of ‘mindblindness’. International Review of Psychiatry 1990; 2: 79–88.
5 Willey LH. Pretending to be normal: living with Asperger’s syndrome. London: Jessica Kingsley Publishers; 1999.
6 Baron-Cohen S. Autism and Asperger syndrome. Oxford: Oxford University Press; 2008.
7 Winnicott DW. Holding and interpretation. London: The Hogarth Press; 1986.
8 Bogdashina O. Sensory and perceptual issues in autism and Asperger syndrome. 2nd Edition. London: Jessica Kingsley Press; 2016.