I begin with a confession: I’m an idealist. They say an idealist is someone who envisions an ideal world rather than the real one, and I say: ‘What’s wrong with that?’ My ideal is to make one-to-one connections with my clients and build an alliance with them that becomes the foundation of our work together and results in an experience that is better than they may have expected.
Of course, there are many reasons that might make alliance building and psychological contact with a client a little tricky, and we need to expect this from time to time. On those occasions, balancing idealism with a little realism is good. Alliance building with an autistic client can be delicate and uncertain, but I believe it’s worth much effort on our part, supplemented by knowledge and that good pinch of realism. I’m aware that there are children on the autistic spectrum who are unable to make connections on an emotional level with the outside world and they are not candidates for our counselling services. For those young people, we must ensure a robust assessment process and thorough communication with the adults in the child’s system to ensure non-malfeasance and respect for all concerned. However, there are many other children and young people with a diagnosis of autism with whom we can work well, and that is what I’m encouraging.
The following definition of autism seems good to me because it’s written with contributions from parents of children who live with this particular type of brain function.
‘With onset in the first years of life, autism presents as a disorder of profound social disconnect rooted in early brain development. A child with autism may appear unaware of his surroundings. He may also fail to respond to the sights and sounds of a social world. Often, with limited speech and language skills, the child follows a different development pattern compared to other children in the same age group. He has difficulty playing with other children and making friends. Alone, the child engages in restricted, repetitive behaviour that is hard to understand.’1
We must postulate, then, that alongside such social communication difficulties, unusually narrow interests and strongly repetitive behaviours, both the child and the people around them face a myriad of obstacles as they try to live side by side. This is where my idealism can be helpful. Yes, there are difficulties, but we also have knowledge and advances in human research that can come to our aid when working with a young person with this type of brain function. And knowledge can help us equip the young person and those around them to improve the shared experience. Here, I want to look for some practitioner help from neuroscience.
Using neuroscience to help
Neuroscience research is tremendously helpful to us as we seek to understand and work with autistic brain function. However, it remains vitally important that, in accordance with the BACP Ethical Framework, we respect each person as an individual and make use of our own assessment structures and face-to-face enquiries in order to understand the capacity of the client in front of us and avoid assumption and generalisation.
One fascinating part of the brain is the limbic system. It’s responsible for emotions, survival instincts and memory. Two parts of the limbic system, the amygdala and the hippocampus, are worth our attention. What we can learn about these brain parts through published research will show how useful to us neuroscience can be. Because the amygdala and the hippocampus are at the heart of the limbic system, and because the limbic system itself is the central information processor for the human brain, it is profitable to explore the impact of autism on these regions and how that may inform our therapy.
We know that the amygdala is often called the alarm system of the brain, the mechanism by which we ‘read’ or intuit social situations to ensure our appropriate response, and also to identify danger or safety. Boucher informs us that the hippocampus is joined to the amygdala and helps humans process and retrieve two kinds of memory, declarative memories and spatial relationships.2 In other research, Cambridge scientists were the first to discover that the amygdala is underactive when people with autism are trying to decode emotional facial expressions.3 In autism, an underactive amygdala can therefore lead to difficulty in processing the danger or safety of situations, and thus a delay when deciding on action. And if the hippocampus is responsible for memory retrieval of previous events or situations (in order to use this previous information to produce an efficient understanding of current situations), then it’s not hard to extrapolate the difficulties a young person with autism will experience in a life when many events and conversations seem to happen simultaneously. Delay or inefficiency in these two crucial brain functions may lead to a young autistic client being in danger without sensing it, or they may respond as if in danger to a situation which has previously been enjoyed and contains no actual danger. This interpretation and the resulting actions can lead to confusing consequences for all involved.
How can this help our work with the client?
We must begin with the rudimentary: be ready to respond to any danger in our environment and not assume the young person will have the same awareness as we do – scissors, heavy books, plastic bags and containers, open doors, precarious storage systems. If there can be poor memory retrieval, we should perhaps explain the dangers as if for the first time (and perhaps over and over again). In addition, Elysa Marco writes extensively about the fact that children with autism show no mirror neuron activity in the inferior frontal gyrus, and she helpfully reminds us that one of the classic features of autism is decreased eye-to-eye gaze, and the decreased ability to read facial emotions.4 The message I take from these observations, and from the neuroscience information above, is to be patient, to use repetition in a patient, purposeful way and to ensure a pace of communication and activity within the therapy room that offers the optimal chance of the young client processing and responding to events in a meaningful way.
As an example, my son is an amazing adult who has lived with, and continues to manage, his autistic brain function with great aplomb. However, a lasting memory for me is the frequent request he made to me as I collected him from school: ‘I knew the answers to three questions today, but the teacher couldn’t wait. Can I tell them to you now?’ We had brilliant conversations as he took great pride in declaring the answers and the learning he was gaining – but he was learning and articulating at his own pace, and the world did not always want to wait. So we must give our young autistic clients the time they need to choose responses from the vocabulary they have and the meaning they are accruing from life as they see it, and encourage others around them to do the same. Our advocacy for these young clients can be a vital aspect of the therapy we provide.
The definition I used at the beginning of the article reminds us that repetitive behaviours and narrow interests can be obvious with autistic children, and I want to say, let’s use this knowledge to influence our therapeutic work. I call the narrow interest and repetitive behaviours ‘straight-line thinking’. Children with autism colour ‘between the lines’, as it were, and that’s where we should meet them. If they have few and very particular ways of thinking, I encourage us to discover the way they’re seeing the world and what holds their interest in it. Our sessions are short, and the context we’re in will often mean a time-limited service, and so we should use the time wisely and respect the somewhat narrow thinking we can identify.
I’ve therefore found it really useful to discover their interests – the particular subjects they know lots of details about and which excite them. Using these subjects as the foundation of our narrative builds a good working vocabulary in the therapy room. For example, if a child is extremely interested in a TV programme, video game or book and is constantly thinking and talking about certain characters, we need to learn more about these things for ourselves. Parents and teachers will often want the ‘obsession’ dismantled and replaced with ‘real world’ subjects and narrative – and we can empathise with these adults to a degree. But we need to also remember the neuroscience we’ve thought about – the autistic brain’s difficulty in general memory retrieval and appropriate threat responses. If we discover the already-formed interests and then use the straight-line thinking they already employ, we are much more likely to increase awareness and comfort for our young autistic client via these familiar characters and objects.
A good example would be a young person who spends a lot of their inner thinking and outward speech describing the events of their favourite TV programme, let’s say Fireman Sam. In this scenario, we need to become familiar with all of the characters and the roles they play in that series. It’s a great expansion of the child’s vocabulary and thinking if we set up a conversation with a character from the show about how to help with homework or friendship worries. My experience is that these children have a developed sense of these characters, and so an additional conversation topic is more easily accepted into their existing ideas of the character. I allow the child to fill the conversation narrative for most of the time. They decide what the character might think and advise, and I might ask for examples of how that would work in the child’s context (‘what would Fireman Sam say about homework and what do we need to tell him about your teacher and friends?’). Obviously, we’ll need to give the young person time to think and allow them to find their own ways of processing the thoughts that our sessions and conversations ignite. We must make no assumptions about their interpretations, and also spend the necessary time exploring how the young person describes what they are seeing and thinking. ‘Listen more than talk’ is my motto. Many times I’ve been thinking I had a ready-made solution for the young person, and in my pragmatism wanted to present this imagined solution with erudite confidence at the earliest possible juncture in the work – only to hear them say that someone else had already delivered a similar version of my solution, which the young person then dismantled as preposterous and evidence that ‘people just don’t get me; they want me to be like everyone else’.
So we need to encourage them to be themselves and encourage their system to accept them for who they are. The straight-line thinking of an autistic brain can be refreshingly uncomplicated and very worthy of being respected. Some points to bear in mind might be:
- Constantly attempt to see their world the way they do.
- If something is distressing them, address it within the existing structures and interests that the young person employs.
- If something is bringing distress only to those around the young person, be careful to respect the young person’s perspective and not simply work on the change that others are seeking.
- Involve others in the structures we are finding success with – for example, in the ‘Fireman Sam’-type conversations. These can be introduced in the classroom and at home so that the young person feels more understood, accepted and collaborated with.
Therapy with a young autistic person can be challenging for a number of reasons: we need to understand the way the condition affects the different brain functions, from cognitions to physical movements. We need to be customising our approach to meet the capacity of the individual. And, dare I say, we do need to balance our idealism with our realism. It’s essential that we access the supervision services of someone who has understanding of this type of brain function; someone who can provide for us in line with BACP registrant’s supervision recommendations:
‘A specialised form of professional mentoring provided for practitioners responsible for undertaking challenging work with people. Supervision is provided to ensure standards, enhance quality, advance learning, stimulate creativity, and support the sustainability and resilience of the work being undertaken.’5
If supervision can provide us, as practitioners, with a crucible for safe learning, processing and proper accountability, then our work with young people living with autism will be more sustainable and ultimately beneficial for all involved. That may be my idealism talking, but that is an outcome I want to aim for with every young person I have the privilege to come alongside in my therapy room, and I want to encourage us all to aim for this too.
Phyllis Coulter is a BACP senior accredited psychotherapist and supervisor in private practice, working with adults and young people over many years in both statutory and private practice settings. She also provides training to practitioners who wish to develop skills and learning in order to work therapeutically with children and young people.
1 http://readingroom.mindspec.org/?page_id=6203 (accessed 15 April 2018).
2 Boucher J, Mayes A, Bigham S. Memory in autistic spectrum disorder. Psychology Bulletin 2012; 138: 458–496.
3 www.neuroscience.cam.ac.uk/research/cameos/AutisticBrain.php (accessed 15 April 2018).
4 Marco EJ, Hinkley LBN, Hill SS, Nagarajan SS. Sensory processing in autism: a review of neurophysiologic findings. Pediatric Research 2011; 69(5): 48–54.
5 www.bacp.co.uk/media/1479/bacp-registered-member-supervision-guide.pdf (accessed 15 April 2018).