This document provides information about autism and working with autistic clients. It begins with a quote about being different and unique. It then defines autism as a spectrum of brain development characterized by differences in social interaction, communication, and repetitive behaviors. It discusses common misconceptions about autism and defines Asperger's syndrome. The document then compares clinical and non-clinical viewpoints on autism. It discusses the importance of the therapeutic relationship when working with autistic clients and potential therapy approaches. Finally, it highlights considerations for therapists and issues clients may face.

1. +
AS CLIENTS -- ―KNOWN BY THE SCARS‖ (Gal. 6:17)
Autism Conference, Mansfield, Brisbane
Qctober 26, 2013

2. “Being different is what sets you apart from everybody else
in this world. It allows you to be unique. It allows you to
process information in ways that people will never
understand, and see things in ways that others find
unimaginable. It allows you to break free from the mold of
society. You are not the same as anybody else, yet you
are no different to anybody else.
You are YOU… Don’t lose sight of this truth!”
-Autistic-ally Beautiful

3. +
Firstly – What is Autism?
Autism is a generalized term describing a complex
spectrum of brain development (i.e. neurodiversity)
Because of the differing degrees and variety of
characterizations, the term Autism Spectrum
Conditions (ASC) is often used to describe the entire
range.

4. +
Firstly – What is Autism?
Autism is generally characterized, in varying degrees, by
distinct differences in social interactions, verbal and
nonverbal communication and repetitive behaviours. (i.e.
‗stimming‘ or perservations). These so-called symptoms
fall on a spectrum, which help account for the variations in
characteristics from person to person.

5. +
Misconceptions (Myths) about AS
(Dominant Ideas that influence how we interact with Autistic people)
•
If a person has AS, they are mentally challenged
•
A person with AS can‘t think, feel or express emotion
•
People with AS don‘t understand humor
•
If someone has AS, then they are simply an introvert who
does not want friendship
•
All people with AS are the same
•
Anyone with AS will struggle to be good at anything
•
Someone with AS is weird or seems a bit odd — but their
eccentricities will pass over time…

6. + then – What is
So
Asperger‘s Syndrome?
•
Between 1994 - 1999, the DSM – IV described
Asperger‘s Syndrome as a response to a common
misconception of a link between autism and
intellectual impairment.

7. + then – What is
So
Asperger‘s Syndrome?
• In mid-2000‘s, considerable controversy raised about
whether AS and HFA differed qualitatively or quantitatively
(Frith, 2004; Howlin, 2002; Miller & Ozonoff, 2000).
• In 2012, the DSM – 5 eliminated Asperger's Syndrome and
replaced it with Social Communication Disorder as a sub-type
of the family of Autism Disorders.

8. From my own experience, ASpie‘s often present as:
• Articulate
• Intelligent
• Often opinionated
• Seen as effusive
• Inflexible (change is unwelcome; B & W views)
• Quirky, Eccentric or ―Nerdy‖
• Lonely
• Confused / flappable
• Very often angry at life
If, as a therapist, you suspect your client might be AS, then what?

9. +
DOES MODALITY MATTER?
(Ideas that may influence WHAT MODALITY we might want to consider)
ASpie‘s tend to push everything they encounter
through what I term the ―logic gate‖. As such,
three things seem paramount to modality.
Let‘s look at several facets of this that seem to
make a difference therapeutically --• Cognitive Functioning
• Perceptual Experience
• Emotional Reactivity

10. +
DOES MODALITY MATTER?
(Ideas that influence WHAT MODALITY we might want to consider)
Thinking processes
– ‗Specialist‘ mind
The patterned thinker
Abstract thinkers i.e. engineers, computer programmers
Verbal thinkers
– Memory capacities
Eidetic memory (visual, anterior cingulate cortex)
Task-specific working memory
Heightened sensory-perceptual behaviours and emotional (empathic) lability/
capacity
How does the client ―see‖ their own emotional quotient (EQ)?
Do they tend to put sensory info into categories?
How do they understand ―meltdowns‖ if they experience them?
Communication and Relational understandings
Interrupt others frequently; egocentric perspective
Repetitive style (say the same thing 4-5 different ways)
Go around & around the barn (never through it) yet demand the latter of others!
Cannot understand why/how their own behaviours affect others
Do they have any life experiences that ever demonstrated ―bridges to empathy‖?

11. +
Comparison of viewpoints
CLINICAL



NON-CLINICAL
―AS is ‗personified‘ by what one might call
the ―Holy Trinity‖ of differences -- a triad
consisting of marked differences in
communication, social skills, and cognitive
and behavioural inflexibility.‖
From my clinical experience, I consider
ASpie‘s to have a different, not defective,
way of thinking. The person may:
―With AS, inflexibility is manifested as a
dislike and avoidance of change and can
also be the presence of obsessional ideation.
Many persons with AS are typified as
‗idealists‘, and often see themselves as
‗perfectionists‘ and ‗realists‘.‖
―Many adults with AS can ―hold it together‖
with single-minded concentration on an
academic or vocational skill that allows them
to make use of their often well-developed
systematic thinking abilities.‖
(Ghaziuddin M, 2003)





Have a strong desire to seek knowledge, truth and
perfection with a different set of priorities than would
be expected with other people.
Have a different perception of situations and sensory
experiences. The overriding priority may be to solve a
problem rather than satisfy the social or emotional
needs of others.
value being creative, rather than co-operative.
perceive errors that are not apparent to others, giving
considerable attention to detail, rather than noticing
the ‗big picture‘.
be renowned for being direct, speaking their mind
and being honest and determined and having a
strong sense of social justice.

actively seek (and even enjoy) solitude.

be a loyal friend and have a distinct sense of humour.
(Attwood T, 2005)

12. +
Comparison of viewpoints
CLINICAL
NON-CLINICAL
Many AS adults are employed and
married with families: often having
developed adequate social behaviors.
What they often lack is a deeper
understanding of other people‘s
unspoken intentions or motivations in
communication, their ―hidden
agendas.‖ AS adults do not
understand ―office politics‖ and,
therefore, make repeated mistakes in
their dealings with others at work.
They are often unaware of the role
their social behaviors may play in their
relational issues. In other words, they
lack ―Theory of Mind‖…
Social anxiety is common among
adults with AS, but it is proposed
that this anxiety derives from a
different source from the anxiety
experienced in social phobia.
Many adults claim they have
anxiety related to their inability to
anticipate what might happen in
social situations. Thus, individuals
with social phobia are made
anxious by what they misinterpret;
individuals with AS are made
anxious by what they cannot
interpret…
(Ghaziuddin M, 2003)
(Attwood T, 2005)

13. +
Neurological considerations
Neural wiring in an AS cortex can be
2.4 to 10X as dense as that imaged
in a non-AS brain
For visual thinkers, we know that
certain neural pathways are
―enhanced‖ i.e. Temple Grandin‘s
visual cortex scan (fMRI)

14. +
Language = use of ‗visual language‘, metaphorical i.e. ―How
does that look to you?‖ instead of ―How does that make you
feel?‖
Focus on
these

15. MOST HELPFUL: use imagery where possible
i.e. ―heart-mind struggle‖

16. The person with Asperger‘s Syndrome can have
difficulty with the management and expression of
emotions. There may also be problems expressing the
degree of love and affection expected by others.
Regarding emotional regulation, many ASpie‘s seem to
notice having an inability or an exaggerated emotional
reactivity.
(Hill, Winston & Frith, 2006)

17. +
3-brain theory
Nathan Mikarere-Wallis (2013)
speaks to the ‗triune brain theory‘…
in order to get a better grasp of
emotional reactivity, it helps that the
therapists strives to ensure we ask
our clients to develop their 3rd Brain:
•
First, calm Brain #1 ( the brain
stem)
• Validate Brain #2 ( the Limbic
system) where endorphins,
adrenaline, and thus emotions,
rule!
• Try to speak to Brain #3 (frontal
cortex)
Taken from
http://www.radionz.co.nz/national/programmes/ninetonoon/au
dio/2560924/parenting-with-nathan-mikaere-wallis

18. Most Aspie’s call these
―meltdowns‖
OCCASIONAL SENSORY OVERLOAD
+
peculiar perceptions and difficulties in the processing of sensory
information with occasional overload.
problems in processing information from more than one
modality.
(Chamak, Bonniau, Jaunay & Cohen, 2008, pp. 274-76)

19. + Can Aspie‘s feel Empathy?
―THEORY OF MIND‖ ARGUEMENT
CLINICAL
Studies assessing the ability of
individuals with ASC to identify
emotions and mental states from
context have also shown deficits
relative to the general population or to
other clinical control groups (BaronCohen, Leslie & Frith, 1986; Fein,
Lucci, Braverman & Waterhouse,
1992). These difficulties may be related
to a failure to pick up the right
emotional cues, and/or to a failure
integrating them, explained by weak
central coherence in the cognitive level
(Frith, 1989), and under-connectivity
between brain regions in the neurobiological level (Belmonte, Allen, et al.,
2004; Belmonte, Cook, et al., 2004;
Critchley et al., 2000)
NON-CLINICAL
“… what if what looks like coldness
to the outside world is a response to
being overwhelmed by emotion – an
excess of empathy, not a lack of it?
This idea resonates with many
people on the spectrum and their
families. It also jibes with the
"intense world" theory, a new way of
thinking about the nature of autism.
The problem is that it all comes in
faster than most can process it.
There are those who say autistic
people don't feel enough. We're
saying exactly the opposite: They
feel too much.“
(Markram & Rinaldi, 2007)
(Chapman & Baron-Cohen , 2006)

20. +
Can Aspie‘s feel Empathy?
COMPLEX / INTENSE WORLD THEORY
Empathy may appear absent for one
of a several reasons—either:
1.
because we feel it but don't
know how to express it;
2.
because we simply can't relate
to a situation—i.e. it's
something we've never
experienced before so we don't
know how it feels, or,
3.
because we feel shame so we
shut down to self-protect.
"If anything, I struggle with
having too much empathy",
one person says. "If
someone else is upset, I am
upset. There were times
during college when other
people were misbehaving
and, if the teacher scolded
them, I felt like they were
scolding me.―
(Client #3 aged 22)

21. +
COMORBIDITY
Alexithymia — have great difficulty
identifying and describing internal
emotional states
Anhedonia — the inability to experience
pleasure from activities usually found
enjoyable, e.g. exercise, hobbies, music,
sexual activities or social interactions.
May result from the breakdown in the
brain's reward system, involving the
neurotransmitter dopamine.
ADHD, BMD, OCD, anxiety/depression
Tourette‘s syndrome — very common
comorbidities
(Simonoff et al., 2008)

22. +
Aspie‘s and Depression
LOSS OF POWER triggers ―meltdowns‖
3.
Over pretty quickly and physical
fallout over with in a few hours;
explosive, devastating.
Can last for days or even weeks
and are incredibly crippling,
intense, and psychosomatically
debilitating.
3.
2.
―Tantrum‖ (temper)
meltdowns
1.
2.
1.
Described as being hit with a
baseball bat in the belly and the
head, simultaneously. Some
clients have even described it as
―being paralyzed with grief‖
―Depressive‖
meltdowns
―Bridge burning‖
phenomina
(Simone R, 2012)

23. +
My Pet Curiosity
―BRIDGE BURNING‖ PHENOMINA
1.
the result of depression
meltdowns. The clouds won't
lift so new horizons are sought.
2.
the end result of temper
meltdowns. If an ASpie gets
very angry… they resolve never
to deal with them/it again.
3.
sort of psychic pyromania. It‘s
often triggered by many of the
same things; it's the last straw
of being misunderstood.
―I get depressed, get very
low, kick out at
everything and everyone.
Hate my life, hate myself,
hate the people around
me. I get out of it by
changing as much
around me as possible —
quit a job, leave a
relationship, sell my
house, etc.‖
(Simone R, 2012, p. 183)

24. +
IMPORTANT THERAPEUTIC FACTORS
FOR AS CLIENTS
Establish a Supportive (Empathic) Therapeutic
Connection (i.e. relationship)
How do we do this if the client can‘t even tell the therapist what he‘s
feeling?
Theory of Mind = is this even possible for ASpies?
Can we successfully communicate a caring attitude?
Establish an ‗early warning‘ system for communications
breakdown
Using the therapeutic relationship as a laboratory for
developing new social behaviours i.e. alternatives to
meltdowns; coping with change;
Using specific examples of situations encountered in their
day-to-day lives.

25. +
o
o
o
o
o
o
o
o
o
o
o
THERAPIES THAT OTHERS SAY
WORK FOR AS CLIENTS
Pharmacotherapy
Narrative therapy (Cashin, 2008)
Art therapy (Elkis-Abuhoff, 2008)
Music therapy (Allen, 2010)
CBT/DBT (Gaus, 2007, 2011)
Group therapy (Longhurst, 2010)
Psychotherapy (various)
Sensory Integration therapy (Dawson, 2000)
ABA (various)
TEACCH
‗Life Coaching‘
o
(Bromfield R, 2012, p. xx)

26. +
Psychotherapies (consdierations)
WHAT DO WE SUSPECT???
1.
Some researchers believe
psychoanalysis and other
psychotherapies emphasizing
symbolic constructs, introspection,
and interpretation have not been
found to be helpful in
understanding and treating Adult
AS (Frith, 1991; Wing, 2001; Borthwick, 2012).
2.
Inviting significant others, familiar
with the person‘s life, into early
sessions seems to help therapists
get third-party information about the
client‘s functioning [i.e. ―outsider
witness‖]. (Dallos, 2003; Cashin, 2008).
―Whether therapies …can help adults
with autism … is still unclear. Only
32 studies conducted so far of
therapies for autism are aimed at
adolescents or adults with the
disorder (aged 13–30 years), most of
which were of poor quality, according
to a report published in August 2012
by the US Agency for Healthcare
Research and Quality.
Compared with a previous report of
159 studies of treatments that
enrolled children 12 years old and
under, with autism, it seems adults
are merely lost in the shuffle.‖
(Borthwick, 2012, p. xx)

27. +
HIGHLIGHTING SOME OF THE MORE SALIENT THERAPIST & CLIENT
ISSUES
―INSIDER INSIGHTS‖ – AS THERAPIST/
AS CLIENT

28. +
POSSIBLE THERAPIST ISSUES
LITERAL COMMENTS MISCONSTRUED
Some adults with AS come across as downright rude
new AS patient speak their truth bluntly – may be taken to heart
INACCURATE REFLECTIONS / REFRAMING BY THERAPIST
IMPLICIT ‗CODIFIED‘ RULES
Some adults with AS have developed their own UNIQUE set of codified
rules for how others should act that are based on the individual‘s egocentric
viewpoint (Attwood, 2003)
In my own experience, I‘ve met many ASpies that complain when others
―breach their boundaries‖ it is common for them to: (a) cross the bridge, (b)
burn the span behind them, never to (c) think of the offender ever again!
This seems to be a useful way of ameliorating stressors that lead to
‗meltdowns‘.

29. + POSSIBLE THERAPIST ISSUES (CON’T)
FORGIVENESS / ‗LETTING GO‘ OF SLIGHTS
COMMON CAUSES OF ANGER IN RELATION TO ASC
Being swamped by multiple tasks or sensory stimulation
Other people‘s behaviour e.g. being ignored, prejudice or bias, unjust actions
Having routines and order disrupted
Difficulties with employment and relationships
Intolerance of imperfections in others
Build-up of anxiety.
IDENTIFYING THE CAUSES OF ANGER can be a challenge! It is important to
consider all possible influences relating to the:
Environment e.g. too much stimulation, lack of structure, change of routine.
Person‘s physical state e.g. pain, tiredness,
Person‘s mental state, e.g. existing frustration, confusion.
Treatment the person experiences by those around them.
Difficulties in gauging how well the therapy is progressing, from the client‘s
reactions, which may lead to the therapist questioning his / her effectiveness.
Become mindful of negative reactions to AS clients and how these reactions
might lead them to subtle disengaging from the therapeutic relationship
(counter-transference).

30. +
POSSIBLE CLIENT ISSUES
ERRORS OF COMMISSION (COGNITIVE DIFFERENCES – REACTIONS)
1. Establishing a helpful framework for AS individuals to understand their
reactions --- and to recognize that there are alternative interpretations of
these same social situations.
2. Such factors rely on a therapeutic relationship based on an assumption that
feedback will be constructive and focused on reducing social
misinterpretations.
ERRORS OF OMMISSION (CONFUSION IN SOCIAL SITUATIONS)
3. The therapeutic relationship becomes an impor-tant vehicle for exploring
social interactions, and therapeutic conversations provide opportunities for
looking for available ‗social cues‘ that could be useful / helpful in avoiding these
types of faux pas.