If your client told you they thought they had Asperger syndrome (AS), how would you respond? Would you know what to say, what to ask or what to do? Would you understand what that meant for your client, for their family or how you can best work with and support them?
I have worked with individuals, couples and families where one or more are affected by AS for over 13 years. In that time, I have seen many changes as awareness of this complex syndrome grows. The importance of supporting the whole family is becoming a relevant concern to therapists and to health professionals generally. Yet despite the mass of information and books now available, I am still taken aback when I hear reports of damaging remarks made by professionals to clients with AS. For example, a middle-aged man was asked by a therapist, professing to work in the area of AS, how long he had been affected by this disease. Perhaps more damaging is when a therapist, who disagrees with the idea of labelling, either does not inform the client that they may be on the spectrum or rebukes a client’s request for AS validation. Either of these may leave a client feeling that they are responsible for the difficulties affecting them and their relationships.
I often use the example of dyslexia by way of an analogy to AS to explain the importance of knowledge and awareness. If a person has spent years struggling with reading and writing, impeding their confidence in their intellectual abilities, it can come as a revelation when dyslexia is recognised and diagnosed for them. They now have an explanation for their difficulties. In fact, they perhaps should be proud of how well they have managed, despite dyslexia. It is a similar situation for someone with AS when they become aware that their struggle with friendships, relationships, social interaction and communication is the result of being affected by something they can do little about; and that they are not outcasts, as many have reported being made to feel.1
Having AS does not change a person’s personality. It is a neurological disorder, a difference in the wiring of the brain, not a defect, simply a difference. This difference often only becomes apparent when the AS individual interacts and communicates with others when looking to form friendships or relationships. AS will cause difficulties in communication (verbally and in the reading of body language), social interaction and in the ability to empathise or to see things from another’s point of view. Communication and empathy are key in forming and maintaining friendships and relationships and it is often within this area that the AS individual will struggle, causing feelings of inadequacy, isolation and loneliness. Many find their confidence and self-esteem plummets. It is no wonder that a high incidence of depression has been found within this section of the population.2
Therapists are often the first port of call for AS individuals, their partners and/or family, making it crucial that they are able to recognise the possibility of AS, have knowledge of the effects of the condition and an understanding as to how best to support the client.
Tools for therapists
So what tools as a therapist do you need in your box? What do you need to know? The first stage is reading and gaining knowledge. There are many good books written on AS, both by professionals and those affected directly. A visit to the Jessica Kingsley website for example will illustrate just how many books have been written in the past decade alone that offer the reader an excellent selection of material. The book I most highly recommend is Tony Attwood’s Complete Guide to Asperger Syndrome,3 which covers all areas of AS and is packed full of information.
To work with difference, there needs to be an understanding of exactly what that difference is and how this will affect the interaction between you and your client. To explain this both to my clients and professionals, I use an example of research carried out by Rita Carter, author of Mapping the Mind,4 who wanted to discover how the brains of individuals with AS worked differently to individuals who were classed as neuro-typical (NT). The following is taken from my book The Asperger Couple’s Workbook:5
‘Carter used Positron Emission Tomography (PET), a brain scanning technique that produces a three-dimensional, visual image of the functional processes of the brain. Carter used PET scans on people who had been diagnosed with Asperger syndrome and people who were not affected by Asperger syndrome. What she discovered was particularly enlightening, giving an insight into the differences in thought processing between the NT partner and the AS partner. First, Carter asked each group in the study a logical problem-solving question. Each group was able to come up with the answer by using logic and for each group an area in the left hemisphere of the frontal lobes lit up on the scan. Second, she asked each group a question that required theory of mind to answer the question correctly. Theory of mind is the ability to appreciate the perception of another, the part of the brain that governs empathy and insight. Carter found that in the NT participants another part of the brain lit up on the scan. This area was just below the area of the brain that governed logic. The NT participants were quick to answer the question correctly. However, in the AS participants this part of their brain did not show any activity. Instead the logical part of the brain became active. This suggests that the AS participants were attempting to work out another’s behaviour using logic, but people are not necessarily logical when it comes to behaviour. It is therefore likely that the AS participants’ answer could be wrong (unless they had experienced a similar situation and were able to recall an appropriate answer). It will usually take them longer to find an answer as it will be through logic rather than empathy that they find it.’*
These results imply that an AS individual is relying on the logical route in the brain rather than the empathic route to process information from others that, in many cases, is not logical. People often use double meanings, humour and innuendos in communication, and non-verbal (body) language is responsible for the majority of the communication we share. Clients often say to me, ‘Why is it that people cannot just say what they mean and mean what they say?’
AS individuals are non-verbal and mind reading is extremely difficult for them to apply accurately. This can result in many misunderstandings in communication. When working with an AS individual, it is important to remember that in communication their brains will be working very hard to work out what you are implying; a client will not be able to read you non-verbally. To make communication less stressful for the client, you will need to be very clear, precise and talk in a logical way rather than using emotions. For example, asking the client the question ‘…and how did that make you feel?’ could create anxiety in them as their logical brain attempts to define, discover and explain correctly the exact emotions inside them. Find out from the client how they best prefer to communicate; they may prefer to write things down or you could suggest they use another medium to express feelings. I have found with some clients that the use of colour to describe feelings and numbers out of 10 to express the intensity of the feeling6 can be very successful. AS individuals are often great at visualising – seeing things drawn or written down will eliminate having to mind-read and so reduce their stress.
Just as an AS client will have difficulty reading you, likewise, you cannot presume you are accurately reading them! For some AS individuals, making or maintaining eye contact can be very difficult. Research studies of two-year-old children have shown that AS infants are more likely to study their mother’s mouth than her eyes.6 Non-AS people will look at another’s eyes because they are reading the information the eyes are giving. If you cannot mind-read then there is little point in making eye contact. The brains of AS individuals are already working hard just to keep up to speed in interactive communication. If they have to look at your eyes, or, with some people, even just look at you, they might not be able to concentrate on what they are saying or be able to accurately hear what you are saying.
Communicating in the therapy room
I have learnt over the years not to try to read clients based on what I see and I will give them permission not to look at me. It is worth noting at this point that some AS individuals will make too much eye contact and this can feel aggressive or like flirting when in fact it is neither – often it just means they have tuned out of their face and are no longer aware of the expression they are using, or have learnt to overcompensate. This is often a consequence of being teased at school over poor eye contact. You cannot read an AS person’s feeling by their facial expression or body language. In fact, trying to draw a conclusion from a client’s face could lead you to believe that they are not feeling anything at all. A client may not give any expressions or indicators as to what is going on inside emotionally for them and this has the potential to be falsely recognised as a cutting off from feelings due to trauma or childhood abuse. Although these areas may need to be investigated, this needs to be done with caution, as it is more likely that a client is affected by a low emotional quotient or Alexithymia.
Alexithymia is reported to affect 85 per cent of people with AS.7 Alexithymia is a Greek word which simply means ‘no words for feelings’ and people affected by this condition may find describing their feelings almost impossible. Being asked to do so or to connect with their feelings would be like asking a severely dyslexic client to perform multiple spelling tests in the room. This could be damaging to the client and would certainly not be working according to the BACP Ethical Framework.
To work in a way that most benefits the AS client, it is important that the therapist adapts the session and communication to fit in with the Asperger world. Communication needs to be clear and logical. The client cannot be expected to suddenly acquire insight into what it is they are supposed to be doing; they will need clear instructions and logical options to consider. Counselling for AS clients should not be about trying to bring emotions to the surface; this could cause the client distress – they may not be able to put those emotions into context and leave them behind when they leave the room.
It can be quite misleading if a therapist is working with an AS client and neither are aware that this is the case. The therapists may find themselves faced with a client who is unable to talk about their feelings and also has extremely vague memories of their childhood due to the late development of theory of mind. Put these two things together and childhood trauma and abuse may spring to mind and it might be easy to find yourself going off on the wrong track. Some clients who have come to me have found themselves involved in years of therapy, having become convinced that their difficulties are due to their childhood experiences. They are often left with feelings of anger and resentment and when the true reason for their difficulties is discovered can become even more resentful over the cost and the time they feel has been wasted in previous therapy.
As a therapist you are not in a position to diagnose AS but you are in a position to signpost – just to suggest the words Asperger syndrome can be enough. People with AS are often great researchers; if you give them the word they will look it up and make their own decisions on whether or not they believe this is a possibility. If they do want to explore this, you will need to discuss with them the next step and highlight their choices. They may choose to seek an assessment or may want to take time to read and explore. What is important is that if they decide to continue working with you, you make them aware of the level of your understanding and what you are able to offer them.
Being aware of sensory sensitivity
Another important area to be aware of is whether your client is affected by an over or under sensitivity to sensory stimuli. These could be in the areas of sound, sight, touch, taste or smell. Checking that the environment in which you are working with a client is comfortable for them can make a difference to their level of stress. For example, I used to have a clock in my counselling room that had a noticeable, but not loud, tick. I moved it elsewhere after a couple of clients commented upon the ticking. Being distracted by noise can be detrimental to a client’s concentration on what is being said – many AS clients report finding it almost impossible to hold a conversation where there is background noise.
Further, a therapist needs to try and understand a client’s level of sensory sensitivity, especially when working in the area of sexual therapy. Some clients with AS have reported being highly sensitive to being touched on specific parts of their bodies; this could be the arms or legs, or it might be the erogenous zones. If as a therapist you are using techniques such as sensate focus, understanding what feels good for your client needs to be very carefully explored and understood. It may simply be the type of touch used that causes the problem. One client explained to me that any form of light touching would make them feel like lashing out.
Areas such as smell and taste are also crucial to check out. Some AS women I have worked with have expressed a strong aversion to their partner’s bodily fluids; this can include kissing, ejaculation and oral sex. They can be physically repulsed by any possibility of exchange of fluids and their partners can be very hurt by this as it can cause retching or obvious signs of repulsion. Understanding that this is due to AS and not a personal issue can make a difference and help alleviate hurt feelings. Understanding AS can make a profound difference to a client’s intimate partner, as often they will be struggling to make sense of their relationship and wondering why the relationship is proving difficult to maintain.
Understanding the impact on the family
In order to work with AS clients, you will need to have a clear understanding of both the client and of how AS will impact on their partner/family. Many non-AS partners report feeling emotionally deprived and can appear frustrated and angry over the relationship. They may have spent years trying to figure out what was wrong in the relationship. One non-AS partner discussed with me how she had been told by a therapist in couple counselling that her husband was just behaving like a man; this contributed to her decision to divorce as she felt their situation was hopeless and that no support was being offered. If you work with couples, by the time you see the non-AS partner, they may be feeling desperate to be heard or understood, and your validation of their feelings can be crucial to their wellbeing. In addition, if your client is unaware that it may be AS that is affecting the relationship, the ability to signpost could make the difference between whether or not the relationship survives.
Discovering what works best for your client can give them and you the best possible chance of having a stress-free and beneficial therapeutic alliance. If your client is comfortable and relaxed within the environment you are offering, if they feel you understand them and your acceptance of their difference is non-judgmental, then you will be very privileged to experience the different, unique and special world of Asperger syndrome.
* Reproduced with kind permission of Jessica Kingsley Publishers.
Maxine Aston is a BACP accredited counsellor and has an MSc in Health Psychology. She runs her own counselling centre where she specialises in working with individuals, couples and families affected by Asperger syndrome. She also offers assessments for adults wishing to discover whether they are on the autistic spectrum, in particular whether they have AS. She is the author of three books: The Other Half of Asperger Syndrome (National Autistic Society, 2001), Aspergers in Love (Jessica Kingsley, 2003) and The Asperger Couple’s Workbook (Jessica Kingsley, 2008). She runs workshops to raise awareness in Asperger syndrome for counsellors and professionals who wish to increase their understanding and be able to offer their clients the support they need.
This article was first published in the July 2011 Healthcare Counselling and Psychotherapy Journal (HCPJ), the official journal of BACP Healthcare.
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