They are strangely impenetrable and difficult to fathom. Their emotional life remains a closed book. Hans Asperger (1944)
Many different types of psychotherapy have been used with children and adults with Asperger’s syndrome.
Traditional psychoanalytical psychotherapy
This has very little to offer. The detailed psychoanalysis of the mother and child relationship can be irrelevant to understanding the mind of a child with AS and leads to the mother developing considerable guilt and the child being very confused. AS is not caused by the inability of a mother to love or relate to her son or daughter. Unfortunately, in France, this is the dominant theoretical model and the basis of treatment.
The methods of analysis used are based on a conceptualization of the development of typical children, but children with AS perceive and relate to a very different world. In psychoanalytical therapy, the pretend play of the child is analyzed to explore his or her inner thoughts. The natural pretend play of young children with AS is often an accurate re-enactment or ‘echo’ or a scene from the child’s favourite story and is not necessarily a metaphor for their life or to be attributed with projected meanings. They are more likely to provide factual information than projections of the self. The child is simply describing what he or she sees.
Rorschach Profile
This is consistent with the diagnostic criteria of AS. There is an underreporting of human content, human movement and cooperative movement, and indications of ‘impoverished or unrewarding social relationships’ and ‘social ineptness.’ The responses are also significantly different from normative data regarding the display or experience of emotion and the ability to establish and maintain intimacy and closeness. The test is sensitive to some of the characteristics of Asperger’s syndrome.
Minnesota Multiphasic Personality Inventory
The profile of AS people reflects characteristics of social isolation, interpersonal difficulties, depressed mood, and coping deficits. The personality profile is consistent with the clinical description and also includes discomfort in social situations, social reservation and introversion, shyness, and social anxiety. Also identified are limitations in insight and self- (and other) awareness consistent with models of AS, especially delayed Theory of Mind abilities.
PSYCHOTHERAPY
This can be of considerable value to parents to understand the psychological reactions to having a son, daughter, or partner with AS, and the frustration of saying “I shouldn’t have to tell you”. This comment, often said in exasperation, would probably have been said many times to a person with AS and is usually due to not understanding the nature of AS.
A parent or partner may need insight into the mind of the person with AS from a psychotherapist to facilitate coming to terms with someone who does not relate to family members in conventional ways and provide insight into the associated emotions and necessary adjustments. Having someone explain the nature of AS and the child’s perspective can enrich the relationship between child and parent, and improve the quality of the relationship when a partner has AS.
Children and adults with AS can benefit from psychotherapy, but the therapy needs to be based on a thorough understanding of the nature of Asperger’s syndrome, especially the ability of the person to understand and communicate thoughts and feelings, and the concept of self in terms of self-image, self-esteem, and self-acceptance, base on the life experiences of someone with AS. This will require the psychotherapist to know the latest cognitive psychology research on Asperger’s syndrome, especially the studies on Theory of Mind, executive function, and weak central coherence; to have read the experiences described in the autobiographies, and to be prepared to make appropriate modification to conventional psychotherapies.
What is needed is a completely new theoretical perspective and psychotherapy based not on the abilities, experiences, and thoughts of typical children, but on the different profiles of abilities, experiences, and thoughts of a child with Asperger’s syndrome.
The development of a rapport between client and psychologist is essential., but clients with AS can either instantly, or permanently, like or dislike other people, especially professionals. He will need an understanding of the linguistic profile associated with AS, including difficulties with the pragmatic aspects of language, especially conversational turn-taking and knowing when and how to interrupt, and a tendency to make literal interpretations and to be pedantic. The client with AS will require more time to cognitively process explanations and will benefit from a clear, structured, and systemic approach with shorter and more frequent therapy sessions. Typing the main points from each session should be provided to review those points at the start of the next session.
There are difficulties finding a psychotherapist with extensive experience with clients with AS and meeting the cost of lengthy therapy. Some families will have the financial resources for weekly therapy sessions lasting for several months to years, but may not be possible for most families and not likely to be available from government support services or private health insurance.
Learning about each other’s mind
The psychotherapist needs to learn about the client’s inner thoughts, which can be a considerable problem for people with AS. Self-analysis does not come easy to the aspie, particularly the male aspie. Some never get to the point of being able to look inward and explain outward.
Theory of Mind explains this characteristic. Understanding TofM is required to develop greater maturity and insight into the thoughts, feelings, and intentions of others, and develop the vocabulary to precisely describe emotions.
Conventional psychotherapy relies on a conversation in face-to-face interaction. The client with AS has a limited ability to express inner thoughts and emotions using speech, and greater difficulties processing the therapist’s speech and intentions and deciphering subtle social and emotional cues, making it more confusing and stressful compared to other clients. Using two connected computers or exchanging emails allows a better therapeutic conversation.
Art as a means of expression, such as drawing an event, and using speech and thought bubbles, as occurs with ‘Comic Strip Conversation’, is another approach. Music may more accurately express thought or emotion. In the case of children, re-enacting a scene from a favourite movie or story that resembles the event of emotion, may be useful. These indirect strategies can give a remarkable insight into the inner world of the person with AS.
Past incidents of injustice, to themselves or others, are difficult for people with AS to understand and resolve. Memories of being bullied, misunderstood, blamed, or betrayed can intrude on their thoughts as an everyday experience, many years after the event occurred. The scene can be mentally replayed as an attempt to understand the motives of the participants and determine who is to blame, to achieve understanding and resolution. Comic Strip Conversations can be used to first understand the client’s perception and interpretation of the thoughts and feelings of each participant, and can then provide greater insight into the minds and motivations of the participants to achieve closure. When there is a lack of intuitive insight, the psychotherapist can provide explanations of the thoughts and intentions that were previously elusive to lay to rest the ghosts of the past.
Constructive transference as used with other clients may not be possible, but the psychotherapist can become a mentor, someone who understands and provides education, enabling the person with AS to articulate their perspective and intentions. They can become aware of how their words and actions affect the thoughts of others.
Thus long-term psychotherapy can help the person with AS understand key events in their lives, and cope in a world that does not understand AS perspective and intention.
Concept of Self
Previous experiences and how they affected them help them understand ‘who I am now’ – the concept of self. At some stage in childhood, the person with AS recognizes they are different from other children. There can be four psychological reactions to this realization – depression, escape into imagination, arrogance, and survival by imitation. Psychotherapy can help achieve a realistic appreciation of who they are and recognize their strengths more than their weaknesses.
The person with AS can be very self-critical, one factor contributing to clinical depression. The worst thing about disappointing yourself is that you never forgive yourself fully. Psychotherapy can help reduce self-doubt and self-criticism. The negative self-image can be reduced by the Attributes Activity to help the person identify their qualities, and perceive themselves as someone different, not necessarily defective. Collaboration between family and key people in the person’s life can encourage an increase in successful and pleasurable activities, facilitating greater social success and self-esteem.
the psychological reaction of escape into imagination can become a concern when the fantasy world begins to intrude into reality. It is an understandable reaction to feeling alienated from the real world, but extreme stress could lead to delusions and loss of contact with reality – a psychosis. A child may imagine being a superhero to achieve power and value. Due to previous teasing, an adolescent could develop a paranoid delusion that other people’s intentions are invariably malicious. Psychotherapy using TofM can help to provide a more objective perception and interpretation of the intentions of others.
They may also develop a compensatory self-concept as someone who is superior and will be perceived as arrogant. Therapy needs to include insight into how such an attitude affects relationships and the ability to make and keep friends., as well as the value of admitting to making a mistake and avoiding feelings of anger towards people who do not meet high expectations.
Acting, using a predetermined script can camouflage their social difficulties by not being true to their real selves or understanding who they are. Their personality is determined by the role they take in a particular situation and imitating those who are successful in a particular situation. A professional actor said, “it was only in my adult years I developed my identity.”
Therapy activities for self-identity
Descriptions of self-identity often include low self-esteem about physical and social abilities, but a high opinion of intellectual abilities. People with AS define their personality in terms of what they like to do or collect, but not their social network of family and friends. With their special interest, they may be able to categorize objects and facts according to a logical framework but have considerable difficulty developing a framework for people. The problem appears to be one of immaturity in the concept of characterization.
Very young typical children first divide people either as nice or not nice. The next stage is to describe someone as having several characteristics – a teacher can be kind but also mean sometimes. They start to understand which of their peers are good guys and bad guys, who to approach, and who to avoid. They also adapt their behaviour according to the personality or character of the person they are with. As they develop, they increase their vocabulary to describe different personality attributes and broaden their concept of personality. Eventually, friendship is not based on proximity, possessions, or physical abilities but on aspects such as being funny, caring, and trustworthy, I.e. an appreciation of someone’s mind.
The third stage is to develop a vocabulary of characterization and personalities for others and themselves. Humour can be a valuable component of psychotherapy and education. Animals, objects, special interests, children’s books, new characters or imaginary story writing can be used to develop characterization abilities. Adolescents can use computer games and drama to explore different character types and create a character with their personality and abilities. Adults can read autobiographies of men and women with AS to identify with similar experiences and emotions. They can type their autobiography and review past events with the psychotherapist.
The temperament and character of adults with AS show a tendency to be anxious, obsessional, passive, dependent, explosive, and immature. Problems with self-direction such as having an externalized locus of control assume that their personal feelings of pleasure or discomfort are not due to consequences of their own efforts but due to the actions and intentions of others.
Personal Construct Psychology. This theory has a logical framework and practical therapy that is well suited to the mindset of people with AS. It is based on the principle that people develop their unique models of reality. It uses a repertory grid technique of elements and constructs using a measuring system and mathematical formula that provides a visual and succinct representation of self-characterization, the way the person relates to others, and directions for change in self-understanding and personal qualities.
The elements are people important in their lives and are individually written on a set of blank cards. The words “how I would like to be” and “how I am now” are written on two additional cards. They take two or three cards at random and ask in what ways the people are similar and in what ways they are different. The answer becomes the construct enabling discussion of the two extremes, for example, helpful or unhelpful which are written at the ends of a large piece of paper. The person is then shown all the cards and asked “Who is the most…?, and they place the cards in rank order between the two extremes using similarities and differences between people. A record of the rank order of the elements is made. The cards are re-sorted and the person takes another two or three elements, identifies another construct and the procedure is repeated until several (or sufficient) constructs are identified. The arrangement and their inter-correlations can be analyzed visually and by a computer program.
The psychotherapies of first choice with both children and adults with Asperger’s syndrome are cognitive behaviour therapy and Personal Construct Psychology. |
Adults with AS tend to have immature constructs. One of the likely constructs in AS is intellectual ability and being called stupid is a particularly hurtful insult in people with AS. Intellectual arrogance can develop as part of the personality profile.
For a typical child, to be told that something they have done has made someone happy or proud is a powerful reward or motivator. The altruistic desire to please people is less of a motivator for children with AS. It is preferable to appeal to their intellectual vanity of them and commend the child for their intelligence, and how smart they are, rather than commenting on how pleased the therapist is.
Two of the ultimate goals in life and psychotherapy are to understand and accept who you are. Some people with AS achieve this without formal therapy.
Warwick, a 12-year-old boy: “I would like to see autistic children accepted with our funny ways. I find it tiring and stressful and annoying to spend so much time watching what you do. Sometimes, I just want to be me and I’m glad to be me.”
“I no longer wish to be normal. I embrace my aspieness, I want to share my joy at being me.”
Rebbeca: “I am what you might call one of the idiosyncratic members of society. I am one of the unforgiven. I have been referred to as a space cadet and a freak. Or, depending on your generation, a nerd, a geek, a spaz, or a dweeb. But what’s in a name? I am an Aspie. Of all the names I have been called in my lifetime, I like Aspie the best because it means that I am in good company.”
Liane Holliday Willey’s father: “If people with Asperger’s syndrome had a better press agent, we’d be in charge and not the neurotypicals.”
Donna Williams: “It seemed that other people’s ‘normality’ was the road to my insanity.”
Nita Jackson: “You’ve got to accept yourself for who you are – however tough this may be. Being in denial will only hinder you. Acknowledge your syndrome, research it, and remember that anyone who is unkind to you because of your difference isn’t worth it in the first place. This is easier said than done. I know – I’m not completely there yet! Accepting yourself, therefore, is the key to personal success… And, most importantly, be true to yourself, because ultimately, you only have yourself to depend on.”