Integrative Psychotherapeutic Approaches to Autism
Spectrum Conditions Working with Hearts of Glass
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Integrative Psychotherapeutic Approaches
to Autism Spectrum Conditions
Working with Hearts of Glass
David Moat
Jessica Kingsley Publishers
London and Philadelphia
First published in 2013
by Jessica Kingsley Publishers
116 Pentonville Road
London N1 9JB, UK
and
400 Market Street, Suite 400
Philadelphia, PA 19106, USA
www.jkp.com
Copyright © David Moat 2013
All rights reserved. No part of this publication may be reproduced in any
material form (including photocopying or storing it in any medium by electronic
means and whether or not transiently or incidentally to some other use of this
publication) without the written permission of the copyright owner except in
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under the terms of a licence issued by the Copyright Licensing Agency Ltd, Saffron
House, 6–10 Kirby Street, London EC1N 8TS. Applications for the copyright
owner’s written permission to reproduce any part of this publication should be
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Warning: The doing of an unauthorised act in relation to a copyright work may
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Library of Congress Cataloging-in-Publication Data
Moat, David.
Integrative psychotherapeutic approaches to autism spectrum conditions :
working with hearts of glass / David Moat.
pages cm
Includes bibliographical references and index.
ISBN 978-1-84905-388-4 (alk. paper)
1. Autism spectrum disorders--Treatment. 2. Autism spectrum disorders in
children--Treatment. 3. Psychotherapy. I. Title. II. Title: Working with hearts of
glass.
RC553.A88M656 2013
616.85’882--dc23
2013000394
British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN 978 1 84905 388 4
eISBN 978 0 85700 750 6
Printed and bound in Great Britain
Contents
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . 6
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Chapter 1 Acknowledged, Accepted and Embraced . . . 15
Chapter 2 Integrative Psychotherapeutic Principles. . . . 21
Chapter 3 …And Breathe!. . . . . . . . . . . . . . . . . . . . . . . 31
Chapter 4 Social Coaching . . . . . . . . . . . . . . . . . . . . . . 43
Chapter 5 Goals and Targets. . . . . . . . . . . . . . . . . . . . . 51
Chapter 6 Beyond Words . . . . . . . . . . . . . . . . . . . . . . . 57
Chapter 7 Using Play and Creativity in Therapy . . . . . . 65
Chapter 8 Hypnotherapeutic Techniques . . . . . . . . . . . 73
Chapter 9 Imagery and Story-making. . . . . . . . . . . . . . . 83
Chapter 10 Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Chapter 11 Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Chapter 12 Loss and Bereavement. . . . . . . . . . . . . . . . . 111
Chapter 13 Positive Life Planning . . . . . . . . . . . . . . . . . 119
Chapter 14 New Developments . . . . . . . . . . . . . . . . . . 127
Appendix: Historical Influences on
Psychotherapy for Autism . . . . . . . . . . . . . . . . . . . 133
Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Further Reading: Personal Accounts of Life
on the Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Acknowledgements
My first contact with the autism spectrum came some three
decades ago, when I left the world of banking and insurance
to work in a residential project for adults with autism. The
world of residential care services – and, indeed, autism – is
very different now, but I am indebted to those 18 adults, and
their families, for enabling me to begin my journey alongside
the spectrum. Further gratitude is due to all the people on
the spectrum I have met since then, as I have continued that
journey. I have been privy to some remarkable stories, and this
has fed my understanding and rapport with autism, as well as
teaching me so much about myself.
My career in psychotherapy has overlapped with my autism
journey. I am grateful to Professor Jure Biechonski and his
colleagues for their encouragement towards exploring the value
of psychotherapeutic techniques for autism. Further thanks
must go to all those in my ever-expanding world-wide network
of fellow counsellors and therapists, who have so willingly, and
valuably, shared experience and ideas with me.
There have been times whilst writing this book that I have
virtually ignored my wife, Emma, and yet still she has supplied
me with support, sustenance and, above all, love. It is in this
depository that my especial thanks must be placed.
6
Introduction
Autism is characterised by elements of atypical functioning in
the areas of communication, social interaction, and flexibility of
thought, as well as potential difficulties in sensory integration.
These circumstances mean that people on the spectrum will
have ways of perceiving the world that are different to the
norm. It is these areas of different functioning that can lead to
problems in ‘connecting’ to one’s human environment, and can
thus create the potential for conflict and stress. Perhaps some
of the behaviours displayed by people on the spectrum could
be described as defensive, or reactive to these circumstances, in
much the same way as more neurotypical people might react to
stress or distress.
I have observed elsewhere that, for most people, the place
of psychological and emotional strength is usually at the centre
of a strong, supportive network, where we feel acknowledged,
accepted and embraced.1 The absence of acceptance and
affirmation in our lives is likely to create emotional difficulties.
I see a number of people across the whole range of autism who
have poor self-awareness, poor self-esteem and a very fragile
personality. These issues may present themselves as anger or
anxiety-related dysfunction, or depression, and any of these can
be the result of having to live in situations where one simply
doesn’t fit.
7
Integrative Psychotherapeutic Approaches to Autism Spectrum Conditions
Thus it can be said that an autism spectrum condition in
itself can cause emotional distress, and this can be exacerbated
as the result of feeling disconnected, or misunderstood. This
distress can be worked through using various psychotherapeutic
approaches.
Key Principles
A major clue to opening up pathways of working lies
in acknowledging the autism and its effects. Autism is
characterised by functional differences in communication, social
understanding, flexibility of thought and sensory integration. In
therapeutic terms, these elements can be described as primary
stressors. They can create a perception and perspective on the
world that is very different to that of other people. If we add
a learning disability to the profile, then those perspectives and
perceptions will be altered yet further. These issues are bound to
lead to high levels of social and emotional stress. Understanding
these perspectives is vital to successful therapy.
A second clue to successful working is understanding that
whilst a person’s autism may be a major feature of that person’s
life, there are other things going on for that person as well,
as they do for other people. We all react and respond to our
environment; we all have individual personality traits; we all
have a genetic inheritance of some sort; and we all have an
experience of life. Each of these things affects who we are and
how we react to things. In autism, the impact of these things
may be distorted, but that does not mean we should discount
them.
Third, a therapist should understand that autism affects
those around the individual perhaps at least as much as it
does the individual themselves. An awareness of projection
(a psychological phenomenon in which a person attributes
unwanted feelings to another person), and introjection (the
internalisation of such projections), is vital in unravelling the
sometimes complicated relationships that can develop around
8
Introduction
the individual. A similar awareness of transference and counter-
transference is also necessary. Here, a client may ‘transfer’
feelings about a significant person onto the therapist. Counter-
transference refers to the reverse process, where a therapist
needs to be aware of their emotional reactions to the client.
Understanding a little about group dynamics and disrupted
functioning can also be useful. This can be especially helpful
when considering the effects of the human environment around
the spectrum client.
Other Factors
A solely medical view of autism risks ignoring emotional
stress. A solely behavioural approach risks becoming stuck
in ‘symptom management’. A combination of the medico-
behavioural perspectives risks over-reliance on pharmacological
interventions. An integrative and holistic psychotherapeutic
approach can help to avoid these risks and lead to very real and
lasting progress.
Another factor which is involved in poor outcomes and
overall prognosis is negativity. A doctor might say to a parent,
‘I’m sorry, but your child has autism…’ A mainstream school
might view the autistic child as a nuisance. Peers might view
the child as strange or odd. Poor social functioning might
create isolation and loneliness. And thus the child may develop
poor self-esteem, low confidence and a lack of motivation.
These things can then lead to anger, frustration, depression and
anxiety as the child grows up. Each of these emotional elements
is treatable using psychotherapeutic approaches.
Autism affects those around the individual in various
ways. This is sometimes overt, as in the case of a parent who
quickly becomes depressed and/or frustrated. Sometimes the
effect is more subtle, where these things happen over a longer
period of time. But sensitive psychotherapeutic approaches can
also benefit everybody within the autistic person’s network.
9
Integrative Psychotherapeutic Approaches to Autism Spectrum Conditions
And if the network functions well, it can only be good for the
individual at the centre of it.
This book seeks to explore ways of helping to promote
emotional wellbeing on the autism spectrum. The importance
of rapport is introduced, followed by discussion of some of the
key psychotherapeutic approaches that may be of use. Some
of these are expanded in more detail through later chapters.
We follow a path that moves from relaxation techniques,
through social networks, into Cognitive Behavioural Therapy.
We will look at working non-verbally with individuals, perhaps
through using play and creative approaches. The journey takes
us through the use of hypnotherapy and guided imagery,
story-making, anger and anxiety management, before finally
taking us into Positive Life Planning. The appendix discusses
newer approaches, such as Emotional Freedom Technique and
Eye Movement Desensitisation and Reprocessing, and will
look at some of the historical perspectives around therapeutic
approaches for autism.
Defining Terms
I understand autism to be more of an umbrella term covering
a range of possibilities, rather than a useful diagnosis in itself.
Despite decades of research, diagnosis is still very reliant on
behavioural observation (and is thus quite subjective), and
the term ‘Autism Spectrum Disorder’ (some prefer ‘Autism
Spectrum Conditions’) has to cover an entire continuum.
Currently, this continuum starts at ‘classic’ autism (which might
be described as autism with a severe learning disability), moves
through ‘high-functioning’ autism (autism with perhaps a mild
or moderate learning disability), and ends for many at Asperger
Syndrome (autism with no learning disability). It also has to
cover a range of presentation within each of these categories.
Examples include: verbal/non-verbal/partially verbal; poor eye
contact/good eye contact; hyper-sensitivity/hypo-sensitivity;
isolated and withdrawn/socially inappropriate. Thus, to say
10
Introduction
that someone has autism conveys very little information at all
about an individual, beyond a potential sharing of some key
characteristics, and practitioners have to guard against making
assumptions upon which erroneous treatment is based. This
can risk exacerbating the very problems that the practitioner
is trying to help solve, assuming that the practitioner has not
already decided to refuse therapy for the spectrum client on the
grounds that the client cannot enter into the social contract due
to his or her disability. Later on, we shall see examples of how
we can engage in therapy for even severely learning disabled
people with autism.
I understand psychotherapy to be another umbrella
term, covering a range of therapeutic options designed to
enable people to develop better psychological and emotional
wellbeing. It may involve traditional ‘talking’ therapies, but
can also involve more creative techniques such as play, music,
art, dance, movement, etc., as well as hypnotherapy. Therapists
who combine a number of these disciplines are often referred
to as Integrative Psychotherapists, and I count myself among
their number.
The description ‘neurotypical’ is often used to characterise
people who do not share an autistic perspective on the world.
It was first coined within the community of people with an
autism spectrum condition.
Some practitioners may be surprised to note the absence of a
specific chapter on depression in this book. It is woven into the
text at several points in various chapters, but I have avoided the
temptation to devote a whole chapter to it, on the grounds that
I believe depression to be a reactive defence used in response to
experiences and circumstances. It is not, in itself, an emotion –
it is more a symptom of an emotional system being thrown out
of balance. There are sometimes clear indications for the use
of anti-depressant medication for certain patients, or for the
use of cognitive behavioural strategies. But, as Bill Goodyear
(2008, p.66) points out, resources are sometimes used towards
the short-term goal of managing depression at the expense
11
Integrative Psychotherapeutic Approaches to Autism Spectrum Conditions
of investment in a longer-term goal of creating confidence,
happiness and self-esteem.2
Whilst there are a growing number of people with autism
spectrum conditions undertaking training in counselling and
other therapeutic interventions, it is currently more likely that
a spectrum client will be seen by a neurotypical practitioner.
However, the value of this book is not intended to be limited to
this last group. It is hoped that practitioners of any neurological
orientation will be able to use the information here presented.
Disclaimer
Many of the techniques discussed in this book are in the remit
of trained professionals, who will have received adequate
instruction not only in how to deliver the approaches safely
and ethically, but also in how to manage difficult situations
when they occur. This book is not designed to be a training
or instruction manual, and should not replace robust,
professional and accredited training in aspects of psychotherapy,
hypnotherapy, Neuro-Linguistic Programming, play therapy,
or any of the other approaches mentioned. The book is a guide
for autism-aware practitioners to the various techniques that
might form part of an integrative psychotherapeutic approach.
For information about specific training, readers are directed to
the various therapeutic professional bodies and associations.
Neither is it recommended that any of the techniques
discussed should be applied in any specific case without
appropriate consultation with the client and interested parties.
Practitioners should also be aware of the provisions of legislation
around child protection and the protection of vulnerable adults.
People with autism are individuals, which means that no
two people on the spectrum are alike. Hence caution should be
exercised with approaches that have been successful with other
people – they may not work with the next client. Additionally,
people with autism spectrum conditions have the right to
be fully consulted on matters of treatment and intervention.
12
Introduction
Despite these notes of caution, the following pages contain
a wealth of information about the various techniques that
constitute an integrative approach to the autism spectrum.
Practitioners are invited to explore, and to enjoy, building an
integrative therapeutic relationship with spectrum clients.
13
Chapter 1
Acknowledged, Accepted
and Embraced
The place of psychological and emotional strength is usually at
the centre of a supportive and positive network, where one feels
acknowledged, accepted and embraced. Or, as Leo Kanner, one
of autism’s first pioneers, put it in 1969, ‘Every child, every
adult, everybody wants what I call the three “A”s: affection,
acceptance and approval. If the child has that, regardless of
his IQ or anything else, he will be all right.’3 Many clients
on the autism spectrum who are referred for counselling or
psychotherapy often talk about feelings of disconnection
within their environments. For example, Neil Shepherd
(2011, p.104), a man with Asperger Syndrome, observed that
‘Aspergics, like all autistics and any disabled people, have to deal
with a world that isn’t designed for them.’4 This can drive the
emotional responses that lead to anxiety, depression, anger and
withdrawal. Thus the first rules of psychotherapy in general can
be applied as the first rules of psychotherapy for autism – the
creation of a safe environment in which to explore emotional
responses, and the development of rapport and trust in the
therapist/client relationship.
15
