Long Island Behavior Analysis Conference

Key Issues in Therapy with Adults with Asperger’s

I have several guiding principles when working with adults with Asperger’s Syndrome (AS). First and foremost, people with AS are more like than unlike the rest of us. AS individuals experience the same emotions, thoughts, life situations and challenges as anyone else. Therefore, when working therapeutically, one should not assume that an individual’s challenges are all related to his or her having AS. In fact, part of the work is sometimes to help clarify how the AS piece fits into and affects an individual’s life, and how it does not, and encouraging the person to not overly identify with the label. At the same time, people with AS have important differences that must be acknowledged, honored, and sometimes remediated. Life’s challenges get compounded when a person has AS, and this must be understood and addressed in therapy.

Secondly, all people with AS, like all people in general, are different from one another. Thus the topics I bring up in this article are not a one-size-fits-all list. Rather, the list is an amalgam of issues that many different individual clients have brought to my attention. I am sure there are others I have left out or not yet encountered.

Finally, I believe all clients have the right to take charge of what parts of themselves they would like to improve or change, and what parts they are happy to leave alone. If someone does not want to make a change in order to fit in with mainstream society, that is their business, as long as they are making an informed choice that works for them, rather than simply giving up for lack of skills or confidence. For example, if a client wants to find and keep a girlfriend, I might point out that certain of their behaviors could possibly alienate them from some potential girlfriends, and then let them decide whether they want to work on those behaviors or not.

The first issue I am on the lookout for is low self-esteem. Most people who are different have been subject to varying degrees of teasing, criticism and ostracism. Social rejection can have profound effects on a persons’ sense of well-being (Williams, 2009). Ostracism can lead to emotional numbness and also contributes to anger and aggression (Baumesiter, et.al., 2007). People with AS often grow up with a sense that there might be something wrong with them, develop a sense of learned helplessness, and conclude that the safest and best solution is social withdrawal. Thus, a therapeutic goal is to restore a sense of self-worth and confidence. I am quick to point out strengths, and offer a carefully adjusted balance of empathy and encouragement.

The second issue is self-advocacy and assertiveness. When a person has been alienated socially, has low self-esteem, has challenges reading social cues, or all of the above, it may be tough to figure out what one is entitled to, and how to effectively ask for it. Many of the people I work with are unsure and often unskilled, presenting themselves sometimes as too aggressive, too passive, or a combination of both. Assertiveness and self-advocacy skills need to be encouraged through direct instruction and through developing a positive self-image as a person with AS.

Another issue is loneliness. Most of us have varying degrees to which we need and enjoy solitude. At the same time, most of us have some need for human company at least some of the time. This need can range from having others nearby, to having friends to share activities with, to having intimate relationships. This issue should be addressed and explored in therapy. I make suggestions for how to increase social contact, including social skills groups in the area. For some of the individuals I’ve worked with, I am one of the few people they talk with on a regular basis. For that reason, I make myself more available than a typical therapist might. For example, I allow clients to email me between sessions and will try to respond, if even briefly, to maintain that human connection. This small gesture of responding to an email can serve as a powerful reminder that there is indeed somebody out there who not only acknowledges their existence but truly cares about them as well. I take care of my own needs while at the same time modeling honesty and directness about my own boundaries and needs for space.

Many people, AS or not, bring to therapy past experiences in life that remain a source of suffering. People with AS can be especially sensitive, conscientious, uncertain as to how they or others may have gone wrong, or uncertain as to what is okay to accept in one’s own behaviors. Their minds tend to work overtime, replaying and rethinking past interactions. I call it “flypaper brain.” Thus forgiving oneself and others is frequently a challenging task that might need to be addressed. Sometimes, simply listening patiently to the play-by-play of a troublesome past experience eventually reduces the energy attached to that story and thus it fades away. Other times, I may help a person lessen their personal suffering by a combination of teaching methods for controlling mind chatter and reframing past experience so that it can be understood and viewed from a different perspective.

Sometimes an important issue is coming to terms with the diagnosis itself: understanding what AS is, and what it means for understanding and accepting one’s self and one’s relationships with others. One of my clients was recently diagnosed as an older adult. His wife, however, refused to accept the diagnosis as a way of understanding some of his different behaviors, saying: “You don’t have Asperger’s. You’re just an ass!” Helping this client understand that some of his behaviors were shared among many on the spectrum allowed him to become more self-confident in dealing with his challenging spouse despite her resistance.

Another area to address is learning to cope with stress and anxiety. I offer a variety of cognitive and behavioral strategies including breathing, relaxation, movement and physical activity. I also help a person create and maintain a sustainable lifestyle that honors the individual’s interests, pleasures, and source of meaning, whether it be a sense of belonging or contributing to society, expressing their connection to and gratitude for the earth upon which we all depend, or pursuing a deeply felt passion.

Although perhaps obvious, it is still important to mention that understanding social relationships, recognizing and expressing emotions, dealing with typical people, and developing a workable orientation to social norms and customs are usually important components of doing therapy with people with AS. In this area I do my best to offer honest, direct and sensitive feedback. I give concrete suggestions, specific explanations, help decode language and customs that may be perceived as alien, and offer opportunities to practice through role-playing.

Sadly, there are still insufficient numbers of therapists well versed in working with AS, leaving too many individuals with AS with limited options for support. I urge other therapists to consider this work. I am currently writing a book on the topic in the hopes that the little I know can be shared and help remedy for the lack of trained, sensitive and caring providers for adults with Asperger’s Syndrome.

Dr Irene Brody is a psychologist in private practice specializing in children, adolescents, and adults with Asperger’s Syndrome and High Functioning Autism. Dr. Brody has been leading social skills groups since 2000. She developed the clinical and social skills program for the ASPIE Program, an innovative model school for high-functioning autistic teens. Dr. Brody has consulted for the NYU Child Study Center’s Asperger Institute, as well as for numerous public schools. Dr. Brody also offers training and supervision to professionals, teachers, and para-professionals. Dr. Brody received her PhD in clinical psychology from City University of New York in 1989.

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