“Know thyself” – Socrates
A central focus in autism spectrum disorder (ASD) research and clinical practice are core challenges in social reciprocity and social interaction – the interpersonal. The self in ASD – the intrapersonal – has been paid relatively little attention. This article presents preliminary thoughts about the self and why exploring the self may be important in understanding and helping girls and women with ASD.
The self is a composite of the ways a person defines him or herself. Nineteenth century philosopher William James described two aspects of the self: the “I Self” and “Me Self.” The I Self reflects what people see or perceive themselves doing in the physical world whereas the Me Self is a more subjective and psychological phenomenon, referring to an individual’s reflections about themselves. Researchers have continued to elaborate on this idea, for example, with theories concerning the evolution of the self across the life span, social and cognitive constructs affecting and affected by self, the roles various aspects of the self-play in life experience, the interplay of self with culture, others, and other influences, and ways that suffering results from discrepancies between the actual and idea self. New terms and ideas continue to evolve out of this body of work, namely self-awareness, self-reflection, self-as-agent, and others.
The Self and Autism Spectrum Disorders
While modern psychologists have studied the self in myriad ways, relatively few studies have examined these ideas in ASD. Lind (2010) examined memory and the self in ASD, and argued for a bi-directional relationship between aspects of memory and self-concept. She found impairments in autobiographical episodic memory and episodic future thinking in ASD and concluded that these implied a diminished sense of self, or personal history, and of personality continuity through time. Others have investigated the sense of agency (SoA) embedded in the self. SoA is the experience of initiating and controlling one’s own actions and producing desired changes in the world with those actions and it is a component of the self. The few studies that have investigated SoA in ASD have reported contrasting results, as some have shown this ability to be spared (David et al., 2015) and others, to be impaired (Zalla & Sperduti, 2015). Much else needs to be understood about the many aspects of the self and ASD.
Knowing Oneself: Mentalizing
Mentalization is a form of imaginative mental activity about others or oneself, namely, perceiving and interpreting human behavior in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, reasons). People mentalize for many purposes – to teach, learn, communicate, and collaborate. Intrapersonal mentalization is necessary to know that we are and who we are. There are conceptual overlaps between mentalization and other abilities – mindfulness, psychological mindedness, empathy, and affect consciousness (awareness of emotion) for both self and other. Mentalization lies at the intersection of these concepts and captures the mental state of being aware in the broadest sense – of one’s physical being in the moment, the motives, emotions and beliefs of self and other that drive behavior in the moment, and the ability, on either a cognitive/intellectual or affective (feeling state) level, to use one’s imagination of the mental states of the self and the other (Fonagy et al., 2002). Mentalization is an elaborated version of Theory of Mind (ToM), a central focus in ASD. Mentalization has been studied largely in the field of personality disorders. A recent study (David et al., 2015) found that mentalization (of the other) was impaired in ASD (David et al., 2015) but little attention has been focused on mentalizing or ToM as it applies to the self in ASD.
Link to Social Competence
The relationship between self-awareness and other-awareness and social competence has been investigated primarily in other conditions – personality disorders, alexithymia, and schizophrenia. Clinician-researchers concluded that fostering improvement in self-reflection needs to precede efforts to support or teach “mindreading” or theory of mind in the treatment of narcissistic personality disorder (DiMaggio et al., 2008). Alexithymia is a condition in which a person has difficulty recognizing his own thoughts and emotions. A functional magnetic resonance imaging (fMRI) study compared neurotypical individuals with above-average self-reflective abilities to individuals with alexithymia (non-ASD) and found that those with superior self-reflective ability were more capable of understanding others’ emotions and less prone to painful emotions than those with alexithymia (Moriguchi et al., 2006). In a study of schizophrenia, Corcoran and Frith (2003, 2005) found strong correlations between autobiographical memory retrieval (a component of self-awareness) capacity and performance on ToM tasks. Corcoran (2001) proposed that people rely on autobiographical memory to infer another’s mental state. That is, retrieved memories of one’s own life form the basis for making inferences about another person’s mental state. The notion that self- and other-awareness is also supported by neuroimaging and behavioral research. Neuroimaging research suggests that mentalizing about self and about others activates shared, overlapping although different brain regions. The degree or nature of the difference or overlap in brain region activation depends on the degree to which the individual perceives the other as similar or different from the self (Uddin, 2011). All of these lines of investigation support a rationale for investigating the relationship between self-awareness and social competence.
Mood and Behavior Regulation
The more we are able to distinguish our perspective from other’s, the more we are likely to manage emotions and meet our own needs (Lane & Scwhartz 1987). The relationship between self-representation and self-awareness has not been studied in ASD. Emotional and behavior dysregulation are sometimes crippling challenges for talented, otherwise competent girls with ASD that impede their academic and vocational progress.
Implications for Research and Treatment
Girls and women with ASD need sensitive, individualized, evidence-based support across the lifespan in so many areas. Staying safe in the physical and cyber communities, at school, and in the workplace is of pressing, primary importance. The tasks of girls with ASD are to establish a healthy lifestyle, navigate social and intellectual demand at school and in the workplace, find a career path, and attain a level of independence. Girls need support in establishing gender and sexual identity and negotiating passages through adolescence, young adulthood, adulthood, adult relationships, and, for many, through mother- and grandmotherhood. All along the way, parents, educators, clinicians, and researchers aim to support the maintenance of relationships with family members and peers, manage mood, behavior, and anxiety regulation, and cope with limitations in motor competence, attention, and executive functions.
Clinical practice with girls and women has addressed the need to support the development of identity in both group and individual treatment. For example, in Girls Growing Up on the Autism Spectrum, Dr. Shana Nichols describes activities such as developing the “All about me” book, “What would you rather do?”, journal exercises, and creative activities to encourage girls to understand themselves. Can we develop broader and deeper methods to increase self-awareness and the development of a realistic self-representation? Would this lead to measurable improvements in social competence emotional regulation, and ultimately, quality and richness of life? We know that self-esteem in ASD is important, and we work on “building self-esteem,” but can authentic self-esteem be established without foundation skills in self-awareness and self-understanding?
What Is the Meaning of Self
for Girls and Women?
Two, somewhat contradictory reasons why this is particularly important for girls and women come to mind. Historically, girls and women have derived key components of their identity from their relationships with men – fathers, husbands, brothers, and male workplace supervisors. While for some women, in some societies, in some respects, this has gradually changed, it remains a reality. It is particularly important for girls with and without any mental health condition to consciously prioritize the development of a deep, rich self-representation that incorporates the interpersonal universe that includes boys and men, but also stands on its own.
Second, sex difference research has found that, neurotypical females are generally more competent than neurotypical males at empathy, theory of mind, and other aspects of social competence. Societal expectations and the media are certainly in line with these scientific findings. That society expects greater social competence in females than males is something of an irony for girls and women with ASD. This does not imply that we need to develop social competence in girls in order to meet an unfair or unrealistic standard. Rather, we need to support girls and women in developing their social competence to its fullest capacity for its own satisfying sake and to be safe and comfortable in our social world.
ASD research has historically focused on the interpersonal world of social competence. Concepts of self-representation, self-awareness, and self-reflection have been studied in typically developing people and individuals with other types of mental health challenges but have received little attention in the field of ASD. While girls with ASD have many urgent needs for loving, thoughtful care and attention across the life span, it is important to delve into concepts of self-representation, self-awareness, and self-reflection in ASD in order to understand similarities and differences with typical development and other mental health conditions and develop effective treatment approaches.
Elizabeth V. Roberts, PsyD is Clinical Assistant Professor of Child and Adolescent Psychiatry at The Child Study Center at NYU Langone Medical Center’s Department of Child and Adolescent Psychiatry. For more information, please visit https://nyulangone.org/locations/child-study-center.
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