Embracing Difference in the Therapy Room:
The author explores ways of understanding and accommodating Asperger Syndrome in a couples counselling setting, and with individual clients.
Imagine the following scenario: You are seeing John and Susan, a heterosexual couple in their mid-forties for the first time. After introductions and form filling you ask what has brought them to therapy. Susan starts to describe how they have spent the past twenty years in and out of therapy. She tells you how the last therapist they saw suggested they separate. You ask them to describe the reasons they have spent so many years seeking therapy. It is Susan who answers again, while John stares blankly at your feet. It occurs to you that he has not yet spoken beyond the initial form filling and has not made any eye contact.
Susan describes to you how they never talk and it is impossible to have a conversation with John unless it is about his topic. She sighs as she describes how lonely she feels and how annoyed she gets that he won’t listen to her or ever asks her how she is when he comes home from work. She said it has been like this since the children were born and he started to spend more and more time at work.
You ask John directly what kind of job he does. He glances at you and Susan answers for him: that is the odd thing, she states; he is a senior lecturer at the University and is a Professor in nuclear science. Susan asks you how he can spend all day talking to students and giving lectures, but cannot even ask her what sort of a day she has had.
She starts to cry; you look to see how he responds and he doesn’t. In fact he shuffles his chair further away from her. You ask him if he is aware his partner is upset, he replies, ‘yes’. You ask why he does not try to comfort her. He answers that he does not know what to do. She cries even more, saying how confused she feels because she knows he loves her and yet she feels so terribly alone.
What would you as a therapist be thinking about now? Would you be wondering if this could be a case of undiagnosed Asperger syndrome? If so what would you do? Would you explore more by asking about family history, children, what works well for them, what does their social life consist of? If it became quite apparent that John might be on the autistic spectrum, would you consider signposting by asking the couple if they had considered the idea of Asperger syndrome?
This example is taken from real life. How you work with a case like this is critical because it could make the difference between a couple staying together or not. Accepting and understanding Asperger syndrome can change all the perceptions and dynamics in a relationship. Without this knowledge each partner will be blaming the other or themselves for everything that is going wrong. Self-esteem for both will plummet and both could feel abused and misunderstood by the other.
I have worked as a therapist specialising in Asperger syndrome since 1998 and have now worked with over two thousand clients on the spectrum. I have seen the difference that awareness and understanding can make to an individual, to couples and to families. I link the two words ‘awareness’ and ‘understanding’ because without understanding, awareness will count for little. I have been told many poignant stories by clients who believe their relationships have suffered through the therapy they received. These couples often feel that in retrospect, the possibility of Asperger syndrome (AS) was totally ignored by the therapist. In addition the AS partner often feels they were given tasks that they could not fulfil.
For example, a couple were asked to spend five minutes every evening discussing their emotions.The non-Asperger partner was really excited about this and was eager and ready to spend her five minutes telling him how she felt. After he had listened for five minutes it was his turn, “Go on then” she prompted him…Silence. A couple of minutes passed and she was getting both annoyed and upset. “Oh for goodness sake, can’t you even manage to give me five minutes of your emotions? I am just not worth the effort am I? We might as well call it a day!”
Fortunately, she did not call it a day and when a friend mentioned the word Asperger syndrome she did her research and bingo! They then sought a diagnosis and found a therapist who did understand. They have never looked back. Both have changed how they communicate and are aware of and appreciate more each other’s differences and needs; their relationship is now based on what is achievable and real rather than expectations of what society states their relationship should be like, which was making it destined to fail.
I still encounter therapists who work according to the ‘We do not give labels stance’ and fair enough, if a client does not want information or a label, then I agree with this entirely. This, though, should not be automatically decided if the clients have not been given the choice; it is not the right of a therapist to decide this for the client without their consent. I do not believe this to be ethical. One of the reasons that a therapist may not suggest Asperger syndrome is down to how they perceive it. If they perceive the condition as being very negative or are attaching a stigma to it then they may be reluctant to make the suggestion. If, however, they see Asperger’s as a neurological difference and that by understanding this difference their client and their client’s family can then work with it, rather than against it, then maybe they would be more inclined to signpost.
There are still many myths surrounding Asperger syndrome. Many unfortunately still have a picture of ‘Raymond’ as played by Dustin Hoffman in Rain Man (Levinson, 1989) in their heads when they think of Asperger syndrome and, more recently, ‘Christopher’, the young man described in the bestselling novel The Curious Incident of the Dog in the Night-Time (Haddon, 2004). The author, Mark Haddon, offers an excellent portrayal of an adolescent on the Autistic spectrum. However, it is important not to see either Christopher or Raymond as typical of an individual with Asperger syndrome, because for both of them their capacity to function socially in the world was extremely limited.
Asperger syndrome forms part of a spectrum that I believe travels from severe and classic autism all the way to everybody else. Lorna Wing wrote in her ground- breaking paper that: “All the features that characterise Asperger syndrome can be found in varying degrees in the normal population” (Wing, 1981).
It is possible that autism plays an important part in the survival of the human race as it can give us the capacity to focus, to be objective and in many cases to think outside of the box. I am sure we owe many of our technical and scientific advances to individuals on the spectrum as there is often, although not in all cases, a leaning towards the scientific and mathematical part of the brain.
I start my Couples Workbook (Aston, 2009) with a quote: “Difference can only feel threatening if it exists within the absence of acceptance and understanding.” Not too many decades ago dyslexia was seen as carrying a stigma and was little understood by the majority of the population; those with it were often called names and alienated by their peers. Until acceptance and understanding of Asperger syndrome is developed, people on the spectrum will continue to feel and be alienated by others.
When I run workshops for professionals I use the example of a person with dyslexia. I ask the delegates to think of a person who has spent their lives struggling with reading, writing and spelling, a person who was called stupid, teased and bullied at school, a person who, however hard they tried, still never managed to obtain the grades they knew they were capable of. If that person was in front of you describing their difficulties, would you say ‘Well that’s just you and how you are?’ I ask whether they can imagine the impact on their client, who probably feels they are back in the playground being told they are stupid and it is entirely their fault. It is no different for someone with Asperger syndrome. Many of my clients go through horrendous bullying because they are perceived as different and not as socially adept as their peers, despite how hard they try to fit in. They may have spent their whole life feeling alienated and rejected. If a therapist now tells them that this is just the way they are rather than suggesting there may be a reason for their struggles and it is not their fault, then the client is not being given the choice of finding appropriate support and guidance.
Both dyslexia and Asperger syndrome are a difference in the neurological wiring of the brain. Neither will change personality. It is the experience of how the person is perceived and treated by others that could change personality. If the individual with Asperger syndrome or dyslexia is neither accepted nor understood then this will impact on feelings of self-esteem and value. As awareness of Asperger syndrome increases, it is becoming more and more likely that the individual or couple that come to you for therapy will have already discovered that one or both of them are on the spectrum. As a therapist you would then have to make a choice as to whether to work with the clients or refer them on. Part of this decision needs to be based on your own beliefs and attitude towards Asperger syndrome. Questions you need to be asking yourself are whether you are going to see Asperger first and personality second? Would you know what could be attributed to Asperger syndrome and therefore difficult to change? Would you know what was to do with personality and therefore possible to work with and look to change if beneficial? Do you feel you understand what having Asperger syndrome means? Would you have different expectations from women on the spectrum compared to men? Would you enquire as to whether your client was affected by sensory sensitivity and finally would you be able to be aware of how you communicated and whether you and your client were in fact talking the same language?
All these questions need to be considered and discussed in supervision. If your answer is yes then you are well on the way to being able to offer a service that will benefit your client rather than disadvantage them. There are many books now available for therapists to read and learn from. There are also more workshops and lectures available where the aim is to increase awareness and understanding. It is for the therapist to explore and discover what is available in their area.
Understanding Asperger syndrome and how it will impact on an individual is crucial if a therapist aims to work in this way. An AS client will not be able to come into the therapist’s world; it is for the therapist to work within the Asperger world, using a language that the client can understand. The first, most important aspect to understand about the client sitting in front of you is that they will be processing information in a very different way to that of a non-AS client. Understanding what this means is very important for a therapist to comprehend. I explain this difference in thought processing to clients and professionals by using the excellent work of science writer, lecturer and broadcaster Rita Carter who wrote the very readable book Mapping the Mind (Carter, 1998).
Carter describes an experiment that used a PET scan to compare the thought processing of individuals with AS and those without AS.(Fletcher, Happe, Frith, Baker et al 1995). The experiment showed that an AS individual will, when trying to apply empathic thought, use the logical part of their brain rather than the area of the brain which governs theory of mind. This implies that a person with AS is trying to work out people’s behaviour using logic. Now, logic is great for facts and figures but not for social interaction and inter-communication, as the reality is people are not logical. People do not say what they mean or mean what they say; they will use double meaning, sarcasm and innuendo.
Working with AS clients requires a logical and objective approach. I would not recommend therapies that draw on deep, inner emotions as these could increase stress levels for clients who may struggle to put a voice to those feelings. This could cause overload or a ‘meltdown’, as it is often referred to. If overload occurs it will portray itself in one of two behaviours, a fight or flight response. Fight is like a temper-tantrum; the person may become very loud, very rude and verbally abusive. They may appear to be physically threatening and may break objects or hurt themselves. It will appear that they have lost control. The majority will go into flight. Flight is complete shutdown. In both cases the individual will feel as though their heads are going to explode, they will feel confused and under threat. All they will want to do is run away, run to somewhere quiet, listen to music or get absorbed in their special interest. This will be to allow their brains to process the backlog of information and get back in control. This however could take hours or days to achieve.
If a client is aware that this is what occurs and can be helped by a therapist to understand the triggers and develop coping skills, overload can be avoided. For example, recognising that group situations or social events can be very taxing, and simply being able to make the excuse to get some air or use the bathroom will allow a short respite. Sensory overload can also be a cause of stress and anxiety for an AS client. An over-sensitive reaction to elements such as noise, lights and smell can make life a nightmare. Noise, in particular, can make life very difficult for the client and result in them not being able to concentrate on what is being said or what they are communicating back. AS individuals have been accused of not listening due to zoning out. One young man I worked with would just walk away from a conversation and was accused of being rude. He struggled to understand why as he could not hear what anyone was saying to him so he left. Basically he was looking after himself and finding ways of doing this politely needed to be encouraged. If working with a client on the spectrum, it is always worth checking out that the environment you are offering your client suits them and they are not being distracted by noise, smell or lights.
There is much that can be done to make therapy a pleasant place for the AS client to be and all it takes is a little bit of extra effort, time and patience. People with Asperger syndrome are unique and offer a different and interesting perspective. I learn much from my clients and if you can take the time to come into the world of Asperger syndrome, you will too.
Aston, M. (2009) The Asperger Couple’s Workbook. London: Jessica Kingsley Publishers.
Carter, R. (1998) Mapping the Mind. London: Weidenfeld and Nicolson. Fletcher, P.C., Happe, F., Frith, U., Baker, S.C., Dolan, R.J., Frackowiak, R.S.J., Frith, C.D. (1995) Other Minds in the Brain: a functional imaging study of “theory of mind” in story comprehension Cognition 57 pp109-128
Haddon, Mark (2004) The Curious incident of the Dog in the Night-Time. London: Jonathan Cape.
Levinson, B. (1989) Director. Rain Man. USA: United Artists.
Wing. L. (1981) Asperger’s Syndrome: a clinical account Psychological
Medicine, 11, pp.115–30.
Maxine Aston is a BACP accredited therapist and has an MSc in Health Psychology. She is qualified as a supervisor and trainer and teacher in adult education. Maxine runs her own Therapy Centre where she has specialised in working with individuals, couples and families affected by Asperger syndrome since 1998; she also offers assessments for adults wishing to discover whether they are affected by Asperger syndrome. For more information visit www.maxineaston.co.uk
Image: Bylight at the end of the tunnel by fredericogori