Feeling Alive

“I am eight years old. When I get scared I go into the bathroom. I take off all my clothes and lay on the bathroom floor. Does anyone see me? Can you feel me? I fantasize that I am alive, and being touched all over. I close my eyes and touch myself all over as if someone else is doing it. I feel alive when I do this. I wish someone else would do this. Consume me and make me feel alive. I want to be examined from head to foot. Examined as if I am important.”

What is this autistic boy telling us? It seems that he does not feel alive. It is hard to know exactly what he means by being alive. By speculating, it seems he feels he can make himself feel alive if he actually does what he wants someone else to do – touch him. He seems to be acting out his need to be touched and seen. He seems to be telling us that he wants to be known and that he wants every orifice to be touched and seen.

Every human being needs to be seen, recognized and ultimately touched by another human being. This child has missed out on this opportunity and is thus acting out his need for this psychological touching. It may seem strange that a young child would go to great lengths by acting out his needs through his behaviors. For autistic children this is the norm and must be understood for what it is and what he means through his behavior.

Most typical children can use words to express their needs. Autistic children cannot use words and thus must rely on their bodies to express their needs. We can also say that typical children have had an attachment. It is through an attachment that the child learns how to regulate himself through the mutual regulation process between caregiver/s and infant. During the attachment process we also come to understand ourselves by how our caregivers’ understand, accept, validate and recognize us. The caregivers help the child to symbolize his experiences. Unfortunately, the autistic child has not had the benefit of an attachment to a caregiver and thus is waiting for the attachment process to be completed. It can be said that he has an Incomplete Attachment.

It is also important to note, that all typically developing as well as autistic children have varying degrees of what I call self-agency. Self-agency is the ability to use oneself in relationship to others. In the lowest functioning autistic child he has no self-agency and thus has no words or is echolalic. The higher functioning the child (typical or autistic) the more self-agency he has. The autistic child will always use his body as a substitute for his lack of self-agency. Thus what he tells us through his body is very important for us to understand.

One more key idea is important to cite here. Autistic children when communicating with their bodies are talking about their psychological needs and not necessarily their daily needs. The typically developing child will express the desire to have a cookie, drink some milk, etc. Of course the autistic child has those needs as well, but he uses his body to express much deeper psychological needs such as our autistic boy in this blog. Through his body (unconsciously) and what may seem strange to some, he is telling us he has a deep need to be touched and seen. We can assume that these needs have not yet been met.

A Nonexistent World

"I live in a world where I do not exist. I know I have hands, arms, legs and a brain, but my place in this world is very tenuous. If I leave a room and come back, will the people in the room remember me? I live in constant fear that others will not remember me. Do they have the ability to keep me in their minds? I am never sure if they do or will. I wonder to myself that if I use a loud voice will I be remembered? If I make sure that I am a good boy, will people remember me? The fear of being remembered is coupled with my inability to remember myself. I constantly forget who I am. I have to frequently remind myself, 'You can talk and initiate conversations.' This does not come easily for me especially when I am in relationship with others. At those times, I feel very anxious and forget what I want to talk about and who I am."

What is this autistic boy telling us? It seems he can see himself physically, but not psychologically. He seems to live in a world consumed by fear and the inability to feel recognized by others and by himself. There are two key points that he seems to be telling us: 1) he exists not knowing if others can hold him in their minds and 2) he cannot hold himself in his own mind. He loses his ability to exist in the minds of others as well as within himself.

It is important to make sense of this experience by reviewing what we know about an “Incomplete Attachment.” In the attachment process, the child learns about himself through the eyes and behaviors of his caregivers. He learns how to regulate himself and his emotional states through the mutual regulation that takes place between the caregivers and himself. He learns that it is safe to exist because he feels seen and validated by others. Unfortunately this autistic child has not gained the benefit of what other’s receive within the attachment process – a sense of self, a sense of security, a sense that there is continuity of being, a sense of wholeness, a sense of a personality, a sense of calmness and a sense of a meaningful existence. It can be said that because he has had an incomplete attachment his psychological development is at a standstill and delayed. He is thus left waiting for the attachment process to be completed.

Stern (1985) unintentionally captured very vividly the experience as an autistic person when he described his reason for placing the sense of self in infancy at center stage of developmental inquiry. Taking Stern (1985)* into consideration, I am going to try to sum up what I perceive the autistic experience to be. It can best be described as a state of psychic paralysis, with no ownership of action or will, extreme fragmentation and disassociation and with a deep sense of loneliness and depression. It is a complete state of futility, hopelessness that feels scary and absolute. It feels like a state of never-ending hell analogous to living in a “black hole” with no exit. Life feels meaningless and is filled with ever-present despair. It is a continuous experience of thinking, but with no language to give shape to those thoughts. It is a continuous state of anxiety without the ability to identify the anxiety or stop it. It is a continuous state of confusion without the ability to ask for help or seek clarity. It is an experience of having no way to use the self in relationship to others. It is as if one is living in a “ deep vacuum” with no bottom, top or sides. It is a state of existence without boundaries. It is a state of existence with no continuity of being. It feels as if you exist without a personality. You are a nonexistent being within a shell that looks like a person.

* Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books.

“My Fantasy Family, My Existence”

“I go to sleep every night and visit my fantasy family. They save me from the nothingness of everyday existence. I do not feel alone with my fantasy family. They protect me and make me feel alive. I do not want to have a fantasy family, but sadly there is no other answer. So once again I crawl into my bed and cover my face and dream of being real.”

What is this autistic boy telling us? He seems to find comfort in his fantasy family versus his real family. He creates a family that seems to give him something he cannot find in his relationships with his own family. He seems to depend on this fantasy to exist. This fantasy allows him the control over his existence, which he does not feel he actually has. This fantasy family seems to be a substitute for what he cannot find in his own family relationships. This made-up family can help him survive and give him the psychological ‘strokes’ and validation he may be missing.

He also talks about his life feeling like a ‘nothingness existence.’ He seems to be saying that he cannot be a ‘real’ participant in everyday life and thus his life feels like a state of nothingness. He also seems doomed to this fantasy existence. It does not seem like he wants to live in a fantasy world, but feels there is no other alternative. Finally, he dreams of being real, which tells us that he may not feel in touch with his genuine self.

Let’s make sense out of this boy’s experience with his made-up fantasy family, his nonexistent life and not feeling ‘real’. It seems that this autistic boy is very creative. He knows there are things he is not receiving from his family and so creatively makes up a family that can provide what he feels he is missing. This fantasy helps to sustain the child even if only in a very fragile manner.

He is also telling us that he does not feel ‘real.” I believe ‘realness’ comes out of feeling in touch with one’s genuine self versus living as a made-up or false self. A false self is created when the child complies with the needs of the caregiver at the expense of his own needs. This is done unconsciously between the child and caregiver. When things go as expected during the attachment process, the child gains the needed validation of his affective experience (feelings and emotions) so he can in turn feel a sense of being 'real' in the world. In this child’s experience, he never fully developed this validation so he is left to feel ‘unreal’ and as I also have previously described as having an “Incomplete Attachment.”

“I am too Smart to be Seen as Defective”

“I can't let anyone know how smart I am. I know I am and that is my secret. It has to be a secret because I do not have a personality or self-esteem, but when I get a personality and have self-esteem then people will know that I am smart and that I figured it all out by myself. I figured out all my problems by myself. It is not safe to have anyone help me because they will think that I must have done something wrong. I do not want to be seen as wrong and defective because I am smart. When you are smart you keep your mouth shut. When you talk others can misunderstand what you say or twist what you have to say and make you feel stupid. Because I am not stupid, I will keep my mouth shut and let everyone else put their feet in their mouths. I am too smart to do that.”


What is this autistic boy telling us? I will try to interpret his message. He is telling us he knows he is smart, but cannot let others know his secret. He is afraid that if people find out he is smart he will be expected to do ‘things’ that he knows he cannot do. Furthermore, he does not feel he has a personality or self-esteem, but knows he can potentially have both. He seems to be obsessed with being misunderstood and seen as not smart. By relying on others he feels he could be made to feel stupid. Finally he observes that people tend to put their ‘feet in their mouths’, which he feels he is too smart to do.

Let’s make sense out of this boy’s experience. Within the autism community, I believe the intelligence of people with autism is misunderstood. Autism is not about academic intelligence, but instead about emotional intelligence. This boy recognizes he is academically bright and that his ‘autistic behaviors’ mislead people to think that he is not intelligent. He grasps the problem, but cannot do anything about it. Many people feel that at least some autistic people have limited intelligence. They contribute ‘brightness’ to those that are high functioning or have Asperger’s. Unfortunately for the rest of those with autism they are labeled as less intelligent.

From my perspective, this matter regarding autistic intelligence needs to be reexamined. I believe as mentioned previously that the person with autism does not have a problem regarding his academic intelligence, but instead it is his emotional intelligence that has been delayed. It has been delayed because he has not benefited from a completed attachment. Without a complete attachment, the child, teen or adult displays behaviors that seem to be bizarre, but actually are methods used by the person to cope with his predicament. Unfortunately because an autistic person does not speak or is echolalic, flaps his hands, resists change and does not relate to people, he may be labeled inappropriately as mentally limited. I believe all people with autism are highly academically intelligent. Our emphasis with people on the spectrum should not only be with their academic development, but more so on their emotional intelligence.

“I am Like Petrified Wood”

“I am five years old. Terror is my bosom buddy. It never leaves me. It follows me like night follows day. I cannot move. I feel petrified like “petrified wood.” Every movement, every gesture is scary, beyond scary - frightening beyond belief. Words will not come out of my mouth. They stay in there like immovable objects. Words are frightening. They are enemies. Sentences seem fragmented. When I talk, I feel like one word is on my left and the next on my right. I feel like it will be damaging for me to talk. Every word I say will hurt me. I must not talk. My words are too threatening.”

What is this autistic boy telling us? From my perspective he is saying his fear/terror/anxiety is so big that he cannot manage himself. He is so scared he becomes ‘immobile’ and unable to function as a human being. He has turned to stone like a piece of petrified wood. Some might say he is scared out of his mind. This can also be called a type of hysteria. He is telling us that not only does he feel like ‘stone,’ but also that it feels like his words are stuck within him and are too frightening to use. We can say that words are not easily used if at all by him. Words seem all over the place for this autistic boy. Finally, probably because of his frightening experience with words he has decided that his spoken words are too threatening for others to hear. Thus he decides that he will keep to himself out of fear of hurting others as well as himself.

Let’s make sense out of this boy’s experience with anxiety and his frightening experience with words. From the perspective of an “Incomplete Attachment” we can make sense out of what is occurring here. During the attachment process, a child gains the ability to self-regulate through the experience of mutual regulation with the primary caregivers. Because the autistic child has not had a completed attachment he has not benefited from this regulation process. The child is left ‘waiting’ for the attachment process to resume. Within this state of ‘waiting’ the child is coping with an existence that is very different than for those with a completed attachment. An observation of any autistic child will give us a glimpse into how hard it is to exist without a completed attachment. Each child will have different methods of how he will cope with this unusual state of existence. That is why each autistic child seems so different from another child, but also at the same time can have similar behaviors. Without the ability to self-regulate which comes with a completed attachment the child is left in an extreme state of anxiety. Everything he does is filled with anxiety – moving his body, talking, walking and bodily functions to name only a few.

Therefore, working with those with autism and extreme states of anxiety, we need to 1) recognize that anxiety is a part of the autistic experience, 2) anxiety is the result of an “Incomplete Attachment”, 3) the key to working with the autistic child is to help him have a completed attachment, so the child can learn to self-regulate, and 4) in order for the child to have a completed attachment he needs a caregiver/therapist who can help in the process of mutual regulation.

“Why Can’t I Express Anger?” Part II

Last week I discussed why the autistic person struggles so much with anger. In this blog I will discuss how the parent/caregiver or therapist can work with the person with Autism Spectrum Disorder (ASD) who is angry.

It is important to remember that the child, teen or adult is angry for a good reason. Because the person with ASD has not had the benefit of an attachment, his feelings become dissociated. This means his feelings are separate from his intellect. Overtime his feelings become bottled up and he subsequently appears angry. Thus we can say his anger is due to his inability to easily access to his feelings. This can be his general state of existence. As mentioned last week, people manifest anger in a variety of ways – passive, passive-aggressive, explosive/competitive and assertively. It is rare for a person with ASD to know how to assertively express anger because that would mean that he has what I call a “sense of self-agency.” This means he can use and express his feelings with others. His ability to express feelings will depend on his functioning level. The higher the functioning level the more the person with ASD can access and express feelings.

What can we do to help the person with ASD cope with his angry feelings? The following are suggestions to use when working with an autistic person who is displaying anger: 1) a key skill is to listen to the anger. Listening to the anger of another helps the person to feel ‘contained’ and ‘held’ without literally holding and containing him or her. It is hard to listen to another when their anger is directed at us, but it is critical to listen at that time. It gives the autistic person a feeling of being seen, recognized and taken into consideration, 2) reflect back to the person what you think their anger is about. With autistic people it can be about something specific and at other times it may be about feeling bottled up. It will be up to you to decipher what you think their anger is about. Use your own instincts to judge what the anger is about and the person with ASD will let you know whether he feels heard or not, 3) how can we recognize whether we have identified the anger? The person with ASD (even the nonverbal child) will start to quiet down, change their mood, nod their head or give you some nonverbal gesture that he feels heard. Each person with ASD is different so his or her nonverbal cues for feeling understood will vary, 4) in a few sentences tell the person with ASD what you think the problem is and finally, 5) problem-solve solutions to specific problems.

For people with ASD who are high functioning/Asperger’s you may also want to do the following: 1) help him examine his triggers (what occurred right before his angry outburst), 2) have him own his own feelings by encouraging him to use what is called “I” messages versus “you” or blaming messages, 3) give him coping mechanisms such as – calling for a time out when he is feeling frustrated, encourage him to talk to someone before he gets triggered and teach him how to listen and reflect back the feelings of others.

These are some important ways to think about how one can help the person with ASD cope with anger. As we know, the expression of angry feelings is important for the psychological well being of all people including those with autism. Because someone has autism does not mean they cannot learn how to better manage and cope with angry feelings.

“Why Can’t I Express Anger?” Part I

“I feel all bottled up. I have no outlet for my thoughts and feelings. It feels like I have no control over my feelings especially my angry feelings. I feel if I talk about my feelings, they will explode over everything and everybody. I feel I will fill up the whole room with my anger and these feelings will never end and destroy everything in sight. So I must keep them inside where they do not see the light of day. I must stay bottled up to protect everyone from my overwhelming feelings.”

What is this autistic boy telling us? He seems to be telling us that at times he is in touch with his feelings and when he is, it overwhelms him to such a degree that he feels he needs to control them versus to let them out. He also seems to feel that he has no control over these feelings so he works hard to keep them inside.

Anger is a normal response to feeling frustrated, a loss of control and disappointment. To express one’s anger in a way that others can take is difficult for most people including those with autism. Why do we all have a hard time expressing anger? I believe the young autistic boy at the beginning of this blog stated what many might feel “we feel it will destroy others and we do not feel in control of ourselves when we feel angry.” When someone is expressing angry feelings toward us, we may feel triggered and then become angry back. As a result anger gets anger. Other times particular people or situations may make us feel angry. For example, an authoritarian boss may micromanage us. In turn we might feel controlled and angry. We learn to manage our anger through our early family relationships. Some people manage their anger through competition and explosion, others may be passive and hold in their anger, some are passive-aggressive, and finally some can be assertively angry.

Thus various personality types, people and situations may trigger one’s anger. We all have our own triggers that have evolved and remain with of us as residue waiting for that next trigger to cause us to feel angry. Unfortunately many people have not learned to express their anger assertively and instead rely on early methods of expression such as aggressive explosions, passivity and passive-aggression. We cannot change other people and certain situations, but we can learn and change how we manage anger.

Managing anger for the autistic person is far more complicated than what has been mentioned thus far. Not only does the person with autism have to deal with normal daily triggers, but also their own communication limitations. The autistic person does not have the same outlets for their anger that the ‘typical’ person has. They do not have easy and direct access to their feelings and thus many times when triggered, either explode or keep their anger and other feelings within. They literally cannot manage their feelings because their feelings are dissociated. Dissociation means that parts of the self are not conscious to or available to the person to use in their communications with others. It is this state that the ASD individual lives. Bromberg (1994) believes individuals begin life made up of multiple self-states. Our wholeness develops through a relationship with another person. * Because the autistic person lacks an attachment, he remains in a non-whole state. Thus the individual has different parts of himself that have not integrated. What does dissociation look like: 1) the person who is talking about one thing and then switches to another topic very dramatically, 2) the person who cannot talk about feelings, but can talk about an obscure topic, 3) the person who has a special ability such as remembering dates, but cannot attend to the topic at hand.

Thus the dissociated state of the ASD individual prevents him from being able to consciously access his feelings and therefore be able to express those feelings in relationship to others. Next week I will discuss how one might work with the angry feelings of an autistic person.


* For more information see: Bromberg, P. M. (1994), “Speak! That I May See You” Some Reflections on Dissociation, Reality, and Psychoanalytic Listening. Psychoanalytic Dialogues, 4 (4): 517-547.

“Change Scares Me” Part II

Last week I discussed why the autistic person struggles so much with change. In this blog I will discuss how the parent/caregiver or therapist can work with the child who is resistant to change and needs to control his environment.

It is important to remember that the child, teen or adult is resisting change for a good reason. As I discussed last week, the individual did not benefit from an attachment so everything is ‘scary.’ It is scary because we learn and acquire our knowledge about ourselves as we are going through the attachment process. Thus the person with autism has not had the benefit of understanding himself so thus lacks self-esteem and self-agency to represent his needs to others. He thus is at the mercy of others needs and wishes. We can say he does not have ownership of himself. Once he gains the understanding, recognition and ownership of himself, he will be able to more easily manage change and transitions.

The following are suggestions to use when working with an autistic person who resists change or has a hard time with transitions. It is important to keep in mind that each child will have distinctive ways he likes to be approached. Also each child is unique and therefore the following suggestions are not meant to be “cookie cutter” approaches that fit for every child: 1) generally it is important to approach the child (I will use ‘child’ for the rest of this blog, but the same techniques will work with teens and adults) slowly. Slowness is important because the child is anxious and overwhelmed about new and changing things. Slowness allows the child to feel less anxious and possibly embrace the change, 2) use a low tone of voice that is well modulated, 3) explain in detail what will be happening that is different and also the same. I call this ‘filling in the gaps’. People with autism need to hear constant knowledge of what is happening to help them feel less alone and to know that everything will be ‘okay’, 4) some children respond well to using puppets or toys to act out the change, 5) ask the child for his feelings about the difference and the change even if he is nonverbal or echolalic, 6) use transitional objects (blanket, toy, picture of you) to help in a transition. For example, give him a special toy as you drop him off at school. You are giving him a reminder of you that he can carry with him during the day. When I work with children, I let them take a toy home to remind them of our work together, 7) the child will probably consistently rebel about change until they stop rebelling. You will need to find the best way for your child to navigate change. It will happen and you will need to hold onto hope that he can make it happen. Do not give up if he relapses with new changes, 8) during a relapse/meltdown, hold the child (if he allows it) and talk to him about the fears he might be having, 9) notice the small changes the child makes in attempting to navigate change. When you notice his successes, let him know that you see them, he can than feel good about himself and his self-esteem will improve, and finally 10) think about working with change as a ‘work in progress’. This means there will be ups and downs, but the child will begin to navigate change when he knows he has you along the way and when he can start to see he can claim ownership and mastery of the new situation.

“Change Scares Me”

“Change scares me. I feel as if I need to stay within the boundaries and cannot go outside those lines. I keep everything simple because the boundaries outside of myself are so fixed. It is too scary to step outside of myself. I feel less scared when I keep things simple. If things become too complicated, how will I know how to react? I might be seen, as “wrong” and I cannot let that happen. By keeping everything the same, I will have some control over what to expect. If change happens too fast, I lose control and do not know how to be and react.”

Let’s make sense out of this autistic child’s experience. We can only surmise what he might be telling us. It seems he has defined limits that he cannot go beyond. It is interesting to wonder why these borders got strongly defined. He seems to get too anxious if he goes beyond his boundaries and we may also say beyond his comfort zone. He is afraid that he will not be able to react appropriately if he goes beyond what is familiar to him. He is also afraid that he will be seen as doing something wrong which in turn he needs to defend against. He is also letting us know that having control is important to him because he is afraid he does not know how to act beyond his defined boundaries.

We are all familiar with the person with Autism Spectrum Disorder (ASD) who needs to keep everything in order. If one thing gets out of order the child may either tantrum or immediately correct the ‘error.’ For example, one boy I knew would line up in order his alphabet letters. If I would take the ‘A’ and put it behind the ‘M’ he would immediately put the ‘A’ back in its proper place. Some children will tantrum if they know one way to travel to school, but a different route is taken. Another child might become difficult when the sequence of activities within the classroom or at home is changed.

Change is difficult for all people autistic or not. Change presents an uncomfortable position for us. For example, people typically sit at the same place around the dinner table or may sleep on a certain side of the bed. We all have a reaction to change, if somebody else sits in our chair or our side of the bed. It is normal to feel irritated by these changes especially if another person creates them. We feel our territory has been invaded and we want things to go back to the way they were. We may feel unjustly intruded upon, unfairly treated or even taken advantage of.

This is also true for the autistic person except the person with ASD reacts more strongly and may not know how to regulate himself when a change is imposed upon him. I believe that the autistic person struggles so much with change for a number of reasons: 1) because of an incomplete attachment, the child is not sure of himself and cannot use himself in relationship to others (lacks self-agency), 2) he has no way to tell others how he is feeling or to defend himself, 3) living in this manner may lead the child to closely monitor what he does know and thus keep everything in order, 4) this order may bring him a sense of mastery over his environment and a sense of calm in an internally un-calm existence, 5) when he keeps things in order he knows what to expect and knows how to interact within this controlled world, 6) change to this ‘order’ presents the fear of the unknown which is probably accompanied by extreme anxiety, 7) something new, such as a new route to school or a new food to eat presents unknown possibilities that he has had no experience with and especially no control over, 8) in essence he does not feel prepared to interact with the change. It literally ‘rocks’ his universe.

I believe that change is one of the hardest things for people with ASD to master. I believe the child holds on to not changing because 1) internally he cannot go from one part of himself to another, 2) control or not changing allows the child to feel sure of himself and know what to expect, 3) if you cannot talk and defend your point of view you cannot allow anything to be different than what you already know and have immediate control over, and finally 4) to allow another to impose a change is basically saying “I trust you and myself.” It also says, “I can allow you to have power and influence over me.”

In my next blog, I will discuss how one can work with the person with ASD when the child is resistant to change and needs to control his environment.

Eye ‘I’ Contact and Autism

“Sometimes I practice looking at someone directly to see what it feels like. If I practice long enough maybe it will feel okay to do. I notice that this is important, but it goes against my rules. If somebody made me look at him in the eye, I would probably do it, but you better believe that I would hate him. I will look someone in the eye when I am ready and do it in my own time and space. If someone is trying to fix himself that part is just not ready yet. Have you figured out that I am very stubborn? It's not that I like being stubborn, but I need to protect myself.”

Let’s make sense out of this autistic child’s experience. We can only infer what is going on within him. He seems to be telling us that eye contact does not come naturally to him. He also might be saying, “leave me alone and do not force me to use eye contact.” If he is forced, he is saying he will resent that person’s interference. Finally he is telling us he is trying to fix his situation and does not want to be intruded upon by others.

What do we do about this child’s lack of eye contact? This is a quandary for us because as ‘typical’ people we know that when good communication is taking place eye contact is direct and focused on the other person. With the person with Autism Spectrum Disorder (ASD), this is not the case. In fact it appears to be just the opposite. The urgency is to want the person with ASD to be in the world and be like us. This may cause us to force or demand the child to use eye contact. I believe this is putting the ‘cart before the horse.’

As we know people with ASD struggle with communication and relationships with others. Eye contact stands out as a nonverbal gesture that feels troublesome for those who work with or have children with autism. I believe that the child will start to use eye contact when he is ready. Thus we need to be patient and let it happen in the normal course of the child’s development.

Some thoughts to think about regarding eye contact: 1) the child is not deliberately being difficult by not using eye contact, 2) his body will not let him use eye contact or let him use his bodily gestures as we might be familiar with, 3) this does not mean that the lack of eye contact cannot change over time, 4) as the child develops his ability to communicate verbally, his use of direct eye contact will develop as well, 5) in fact it might be the last nonverbal gesture he will be able to conquer. This will vary from child to child, 6) eye contact is a nonverbal (gesture) communication from the unconscious of a person, 7) when communication is good we say that the person is congruent. Their verbal communication is complimented by their nonverbal gestures (eye contact being only one of many nonverbal gestures). This means that the person will use direct eye contact when he feels more comfortable with his verbal communication and his relationships with others. Eye contact demonstrates the individual’s confidence and self-esteem, and finally 8) a way to think about eye contact is that the child will use ‘eye’ contact when he can use ‘I’ contact.

Keeping Hope Alive: Helping the Child with ASD Navigate the Attachment Process

“Why does everyone know the ‘rules of how to live’? Why do I have to fend for myself? I continue to be a lost child drifting in air and at the mercy and whim of others. My body will not work like those of others. I have no control over my bodily functions. I am not in control, but feel everyone else has control over me. Is there anyone that is listening and do you know what I am saying? Why is it taking you so long to understand my plight? I feel that I will have to live in this never land the rest of my life.”

Let’s make sense out of this autistic child’s experience. We can only hypothesize about what is occurring. This child believes he has been left out of the developmental process. He is very aware that others can function appropriately and that he cannot. He feels no control over his body and feels he cannot make a difference in his own life. He is also looking to others to help him with this predicament. He knows he cannot manage this situation by himself. Finally he believes there is no hope for the future and that his life will forever remain the same and he will remain in a ‘never land.’ He communicates great frustration and hopelessness.

This child is also describing the experience of not having had a completed attachment. From the work of John Bowlby and Mary Ainsworth attachment theory has developed. Without going into the details about attachment theory (if interested review the work of Bowlby and Ainsworth) four categories of attachment have been recognized and it is believed that all people (including those with ASD) fall within these categories: secure, ambivalent, anxious and disorganized. It is my opinion that people with ASD do not fall within any of these categories and have not yet had the benefit of a ‘completed attachment.’ Instead I have proposed a new classification that takes into account the autistic experience, which I call an ‘Incomplete Attachment.’ Instead, the child is left in a dissociated state, unconscious and waiting for the attachment process to be revitalized. If you have never experienced an attachment you are left to navigate the world without a sense of security, trust and ability to use yourself in relationship to others as one would have who has benefited from an attachment. Thus it can be said we are working with a person (ASD) who has no experience of being able to experience themselves in relationship to others. It is important to note that this is a major reason the child with ASD has difficulty navigating interpersonal relationships.

Therefore the process to help the person with ASD is very time consuming, complicated, but not impossible. It is time consuming because we need to start at ‘square one’ in helping the child to develop a secure attachment, trust others, gain a sense of security, develop the ability to self-regulate, to learn to communicate and to express his feelings. All these developmental abilities would have been acquired through the attachment process, which this child has not benefited from. The key purpose of this blog is to emphasize that the time consuming nature of working with those with ASD is daunting, but can be navigated. The child can develop what is called an earned secure attachment, but the development of an attachment will be more time consuming and difficult than if acquired as an infant. The solution is to not give up, but instead to keep the hope alive that the attachment process can be successfully completed for the child with ASD.

Without Words

“I cannot ‘come back’ and defend myself. I cannot respond to others. This is scary, beyond scary. It is terrifying. Sometimes the words seem to be accessible, but as I open my mouth they disappear. In the presence of another, I instantly forget what I was going to say. This happens over and over. I want to talk, but I forget what to talk about. It feels like I am a blank slate. It petrifies me. People on the ‘outside’ expect me to talk. What am I going to do? Sometimes I watch real carefully to see what would be a good answer and give them back what they want. I am pretty good at this. I feel this is the only way to survive. Survival is becoming my middle name. Who would ever understand that I am a blank slate? When I am alone I am not blank, but in the presence of others I am. I am a blank slate walking around in a person's body. Please help me. This is too much for me to know. Who will listen to my burden?”

Let’s make sense out of this autistic child’s experience. We can only deduce what is going on within him. He seems to be telling us he has no ability to respond to others and this scares him very much. He says he wants to talk, but in the presence of others he goes blank. By himself he is not blank and can form ideas and probably has feelings. Finally he feels burdened by this experience and there is a sense of hopelessness and desperation in his writing. In my previous blog, we understood his experience to be a feeling of lack of freewill and control over his environment.

This child is describing the experience of not being able to express himself as he sees others do. It is a tortuous experience, which he seems to lack the ability to change on his own. I believe it is important to note that this phenomenon is probably going on with others with Autism Spectrum Disorders as well. He is describing how relationships cause him tremendous anxiety and cause him to collapse. He is not ‘falling apart’ because he wants to, but because of the anxiety.

How can we help this child who seems to collapse in relationship to people? Some steps that may be helpful for the child and yourself are 1) recognize that he has the potential to communicate, but the presence of another makes him feel too anxious and he ‘goes blank’ or forgets what is on his mind, 2) he is not going blank because he is willful or difficult, 3) help him to understand that you understand his predicament, 4) help him to become more comfortable with others including you. Until his anxiety is under control he will continue to go blank and finally 5) give him the time and space to talk. Create opportunities for dialogue with you.

Anxiety is something that people on the spectrum are always trying to manage. We need to put ourselves in their shoes. If they lack self-agency and dissociate in the presence of others, which creates an inability to communicate their needs than their daily existence will be one of coping and anxiety. People in general remain anxious when they do not have a way to self-regulate. 'Typical' people talk about their problems with others and hopefully find new solutions to manage a given situation or their anxiety in general. Because autistics do not have the ability to communicate their feelings we have to find other methods to help them to self-regulate.

What can we specifically do to help the autistic who is anxious? There is not an easy answer, but some thoughts to consider: 1) Talking about anxiety in general may be helpful. If the child is nonverbal, speak about how he might be anxious doing the specific thing he is doing. If he does have words either ask him how he is feeling or interpret what his anxiety might be like. Let him respond to you. It is important to not expect that he will be able to speak about his anxiety, but at least allow for this to be part of the discussion between the two of you. By doing this he is acknowledged for how he is feeling and hopefully in turn feels understood, 2) make room for the discussion of anxiety as part of the dialogue, 3) let him have the time he needs to warm up to new situations and not be pressured to comply to others' time frames and 4) work on developing a relationship with him that allows for mutuality, dialogue and direct expression of feelings.

Functioning Without a Mind

I feel like I have no mind to use with others. I know I have a mind. It thinks. It sees. It reads. But this mind is different than others. This mind disappears in the presence of others. Others’ minds are the boss of my mind. I am at the whim of everyone. I feel like a ball being tossed from one person to another. I am controlled by whomever I am in front of. It is as if the “other” controls me. I lose myself in the “others” presence. Myself, my mind, does not work with an “other.” It stops and goes blank. It is scary to not have a mind that I can use. It is like others stop me from existing. They have the control and I must adhere to their existence. They have not been left out. They are people.

Let’s make sense out of this autistic child’s experience. We can only guess about what is going on within him. He is telling us that his mind seems to be different than others. In other words, he is aware that he feels different from others. He is also telling us that he has no control over his mind. He knows he can function intellectually (reading, thinking and seeing), but loses access to what is on his mind when he is in the presence of others. Additionally, he is telling us he feels controlled by others ‘very’ presence. It appears that he has no freewill and control over his environment, but instead feels like he is at the mercy of whoever he is in relationship to. Finally, he concludes that others have the control and he must adhere to that control.

This child is describing what I call a lack of self-agency. Self-Agency is the ability of the self to take initiative, to regulate oneself and to be the source of one’s behavior. How can we help this child who lacks self-agency? Self-Agency develops over time, as does the child’s ability to take initiative and to take control over his environment. This does not happen quickly.

Some steps that may be helpful for the child and yourself are: 1) belief and recognition that the phenomenon of a ‘lack of agency’ is occurring and that there is something that can be done about it, 2) explain to him your understanding of a lack of self-agency (optional – but can help some children realize that they have not caused this to happen), 3) remember - the child is not complying or not demonstrating initiative because he is difficult, but instead his body will not let him, 4) the child needs to learn that there is ‘space’ for him in the relationship with you. This is accomplished by always creating an opportunity for dialogue between the two of you (even if he does not speak). He needs to know that you are creating ‘space’ for him with you, 5) give him the time to be in relationship with you. He may feel rushed in the relationship. Let him know that he can take the time he needs to communicate, 6) help him symbolize what is on his mind. For example, when watching television or a video, talk about what you see the people doing and feeling and ask him what he sees and feels as well. Continue to do this in the relationship between the two of you by always asking what he is feeling. If you are playing ball, have a continuous dialogue with him such as “I am catching the ball and now I am throwing the ball back to you and you caught it." This process can be done with nonverbal, echolalic and higher functioning children, 7) Give room for feelings in the relationship – positive and negative and 8) validate and recognize every action of self-agency and initiative he takes. By doing this you are not only reinforcing his attempts at initiation, but also you are helping him become more conscious of himself.

The Forgotten Child

Scarier than anything else is the feeling that I can’t cry, can’t feel, can’t talk. Tears don’t come out of my eyes, never, ever. I hear others talk about feelings. They say, “I love you, I hate you, I hurt.” I don’t feel. Where are my feelings? God must have forgotten about me. “Dear God, why did you forget about me?” I am a lost child. I feel like God forgot to make me into a person. I say to myself, “I must have done something wrong. I was left out.” Forgotten – a forgotten child who must fend for himself.

Let’s make sense out of this autistic child’s experience. We can only speculate about what is going on within him. This child appears to be very aware of his predicament. He can see that others function differently than him, but he cannot seem to do anything about it. He knows he cannot express feelings and thus tries to make sense of his own experience. He believes he was not made into a person like other people and that God must have forgotten about him. It makes sense that he would make up a story or what I call a “narrative” to explain his state of existence. In his story to himself he blames himself for his predicament. He goes on to tell us that he feels forgotten. In that last sentence he seems to have made up his mind that he will remain forgotten and must handle “life” in his own way.

The story he tells us may leave us feeling sad and hopeless for him. I believe that each person with an Autism Spectrum Disorder (ASD) comes up with his or her own story about himself or herself. This is not unique to people with ASD. All human beings have their own narratives based on their experiences. As a therapist, I am always helping clients to understand and refine their own narratives. People with ASD would also benefit from this refinement and understanding of their own “stories.”

How might we help our child with ASD understand and refine his story? The answer depends on the age of the child and his functioning level. It also depends on your perceptions of Autism Spectrum Disorders. From my perspective, I believe the child lacks an attachment, has varying degrees of self-agency (depending on his functioning level) and goes in and out of states of dissociation. From that perspective, I feel there is hope for the child even though he may not feel that hope. In fact, I believe I need to hold onto the hope he may not be able to feel.

Thus in this case, I would work with the child to 1) help him understand that he did not cause the ASD, 2) that there is hope for him even though he may not be able to feel that hope, 3) that he does have feelings, but that they are not available to him now, but that does not mean they will not be available to him at a later date, 3) the work we do together will help him to access those feelings that seem to be missing, 4) he is not alone with this predicament and 5) together we will work to make his life easier.

The point to remember is that our own perspective of the child and autism will influence the child’s story about himself and his ultimate ability to grow and develop. Even if we say nothing, the child will pick up through our nonverbal communication and tone of voice how we feel about him and his predicament. Thus it becomes critical to become aware of our own perceptions about our children and about Autism Spectrum Disorders.

Living Without Boundaries-the Autistic Experience

God, I reach out and I cannot feel myself in time and space. It is as if I am floating in air without any boundaries. It feels like I am in a state of never-ending hell like living in a black hole with no exit. I want to scream, but I cannot talk, I cannot move my mouth, I cannot tell anyone of my dilemma. This hell has become my secret and my secret alone. God, you share my secret. Will I ever find a way out of this hell? God, I am screaming. I am screaming without words. God, these are loud screams, but silent screams. Do you hear me God? Do you hear me?

This is one autistic boy’s communication of a boundary-less existence. This child is talking about what it is like to not be able to place himself into “time and space.” He seems to also feel like he is floating in space with nothing solid below or around him to hold onto. He seems suspended in an existence without any means to communicate his predicament. What does he mean by these comments? I believe he is saying, “I do not feel like I exist. Time and space have no meaning for me. I live in a ‘psychological’ world with no anchors and continuity of being (internal stability). I am terrified by this state of existence.”

It is important to take this autistic boy seriously. He is telling us how he exists. The first step to helping him feel that he has boundaries and to feel ‘alive’ is to believe in his state of existence. An autistic individual’s development is based on how well we can understand his predicament. The better we can understand him, the more he has a chance to exist like any “typical” person. Many people work with autistic individuals by trying to change the child’s behavior. I believe the work needs to be exactly the opposite. We need to change how we understand and treat the autistic person. When we emphasize their need to change than they may never feel validated and are left in a boundary-less existence. In essence when we want him to change we are in fact saying “there is something wrong with you which we do not like.” I do not think this is the message that we want to be sending. I believe that autistic people have a hard time ‘existing’ because people are always reflecting back to them a message that does not reflect how they feel. Thus it is not the autistic person that needs to change, but it is how we understand their predicament that needs to change.

Helping the Autistic Child Develop a Sense of Agency

God, I feel like I have no mind to use with others. I know I have a mind. It thinks. It sees. It reads. But this mind is different than others. This mind disappears in the presence of others. Others’ minds are the boss of my mind. I am at the whim of everyone. I feel like a ball being tossed from one person to another. I am controlled by whomever I am in front of. It is as if the “other” controls me. I lose myself in the “others” presence. Myself, my mind, does not work with an “other.” It stops and goes blank. It is scary to not have a mind that I can use. It is like others stop me from existing. God, they have the control and I must adhere to their existence. They have not been left out. They are people. They have a personality. I do not have a personality. God, why did you leave me out?

This is one autistic person's experience. What is he saying? From my point of view, he is saying, “I do not have control over my body. My body does not work for me like others.” He is also telling us that he can tell the difference between his experience and those of ‘typical’ people. He is explaining to us what it is like to not have a sense of agency. Self-agency is the ability of the self to take initiative, to regulate oneself and to be the source of one’s behavior. The person with autism does not have that ability. He cannot literally control his behavior and his actions. It is not that he wants to be this way, but when one does not have a sense of agency that is his predicament.

He is also telling us that the very presence of another makes him feel that he does not exist. He seems to lose his ability to communicate and thus cannot let us know what is on his mind. And finally he is telling us how scary it is to live this way – no control over his body, no control over going blank and no control over feeling as if he does not exist.

What can we do about his lack of self-agency? 1) We can incorporate within our own belief system that the autistic child does not have control over his body and that he lacks self-agency, 2) we can let him know that we understand that he lacks this control over his body, 3) we can adopt a belief that we need to recognize, validate and understand him, 4) we can adopt a belief that a sense of agency is developed in relationship to another person, 5) we can understand that agency is acquired in the process of interacting with another person, 6) we can understand that the kind of interaction the child with autism needs is our understanding of what he is trying to communicate through his bodily behaviors, 7) Our goal is to not have him compliantly adapt to us. This kind of adaptation to another makes him into a ‘robot’. Instead it is through our understanding, validation and recognition that he can start to see himself and then ‘use’ himself with us, and 8) He needs to see and feel that there is ‘space’ for him in the relationship. This means that he is a partner in the communication with us. Along with giving him space, it is important that he can feel that he has an impact on us. We need to allow him to influence our behavior and thinking. This is accomplished by letting him make some of his own decisions and by letting him sway or change our thinking. By setting his own agenda he can start to feel his power and his agency. In turn, we need to communicate back to him a confirming response

Relational Therapy and an Incomplete Attachment: A New Look at the Etiology and Treatment of Autism Spectrum Disorders - Glossary of Terms

In introducing a new theory of autism, it is important that everyone have a glossary of terms that can be referred to that explains the terminology I use in my writings. This glossary is a ‘work in progress’ that will be tweaked as I receive feedback about how helpful it is.

1. Incomplete Attachment (also referred to as a lack of attachment) - the belief that children on the spectrum have not had the advantage of a completed attachment. Thus during the attachment period of life (birth – three years old) the child has not attached to the caregivers. There are probably many reasons why this has not occurred. It is not the fault of anyone. It is my belief that what one sees when observing children on the spectrum is a child who is waiting for the attachment process to be completed. The child is doing the best he/she can to cope with this predicament. All the behaviors such as flapping arms, nonverbal communication, echolalia, lack of responsiveness to others or inability to communicate one’s needs are coping mechanisms that can make sense when taken from this perspective.
2. Sense of Self-Agency – is the ability of the self to take initiative, to regulate oneself and to be the source of one’s behavior. A sense of self-agency is developed within a relationship with another person. The autistic person has an incomplete attachment thus does not have the advantage of self-agency. The functioning levels of those with ASD correspond with the degree of self-agency the individual has. The lower functioning individual has very little self-agency and thus is nonverbal or can only use echolalia. As the individual gains more self-agency we start to see the use of words such as “me” and “I” as well as more interactive behaviors. Then we start to call the person high functioning.
3. Dissociation – Parts of the self are not conscious to or available to the person to use in their communications with others. It is the state that the ASD individual lives. Bromberg (1994) believes all individuals begin life made up of multiple self-states. Our wholeness develops through a relationship with another person. * Because the autistic person lacks an attachment, he remains in a non-whole state. Thus the individual has different parts of himself that have not integrated. What does dissociation look like: 1) the person who is talking about one thing and then switches to another topic very dramatically, 2) the person who cannot talk about feelings, but can talk about an obscure topic, 3) the person who has a special ability such as remembering dates, but cannot attend to the topic at hand.

* For more information see: Bromberg, P. M. (1994), “Speak! That I May See You” Some Reflections on Dissociation, Reality, and Psychoanalytic Listening. Psychoanalytic Dialogues, 4 (4): 517-547.

Goal V: Application Through Case Discussion- the Autistic Runner

This blog is the continuation of the goals of Relational Therapy. In this discussion I will demonstrate through a case discussion how the caregiver or therapist can utilize Relational Therapy to work with individuals with Autism Spectrum Disorders. This blog along with others will discuss my personal experience working with this population.

Aaron was four years old when I first met him. He was nonverbal and a runner. He was participating in a program for autistic children and I was a volunteer. It is hard to describe why I connected with Aaron, but it was a connection of a lifetime. It is over twenty years later and I still have contact with his family.

I was warned he was a runner, but I thought I could manage this. I did not know what I was in for. I knew that I needed to gain an attachment with him. To help gain this attachment, I would show him lots of attention and would at his request (by pointing) tickle him. He loved the tickling. Sometimes, I noticed he was very anxious and he would climb on the ledge of a window. I would hold his hand and say something like this, “Aaron, I am holding your hand because I am nervous you will fall and hurt yourself. You do not have to get down until you are comfortable.” He immediately would get down. A lesson I learned was to not demand his compliance, but instead to talk to him about his fear with the hope he would respond, which is exactly what he did. Having developed the beginnings of an attachment we explored what it would be like outside the room we played in.

Now I saw what it meant to be an autistic “runner.” He would run fast for a four year old, but I managed to keep up with him. My fear of losing him gave me extra energy to run fast. He would run to a video arcade. He loved the blinking lights with all sorts of noises. Each week this running to the arcade became a ritual for us. I was getting great exercise, but thought maybe we could do this differently. This is where my creativity came into play.

I would stand in front of him as he was running and catch him and thus made his running into a game we could play together. He would soon learn that this game was fun and also he was learning how to interact with me. The attachment was solidified. After sometime, he actually stopped running and began to walk with me. At times I would stop and he would continue to walk. I would call, “Aaron, I am back here.” He would stop and run back to me. I would continue to do this so he would become more conscious of me. Over the years, we took many long walks (over an hour) together.

Runners can be difficult to work with, but not impossible. Developing the attachment is critical, but once the trust is solidified and the child realizes you are a permanent fixture you have accomplished an important first step. You need to believe that through the relationship with you that he will want to walk with you. By making it fun, the child will want to join in. I believe that Aaron not only wanted to have fun, but he also wanted to stop running, but did not have a reason and the knowledge to do so. Together we made it happen.

Goal IV: How to Develop Specific Steps in Deciding Which Techniques to Use When Working with People with Autism

This blog is a continuation of the goals of Relational Therapy. In this discussion I will emphasize how the caregiver or therapist develops specific steps in deciding which Relational Therapy techniques to use with individuals with Autism Spectrum Disorders.


• As mentioned previously, it is important to be flexible. The right technique with a given child/adolescent/adult will develop through spontaneous interaction with the individual.


• In determining the right technique at a given time, take the child’s lead and let him have control. The autistic individual does not have self-agency so by letting him have control you are letting him experience self-agency. As he experiences self-agency you can start to forge an interaction with him. He needs to see that he can have self-agency and he needs to know how to be in a relationship with another person. The autistic person learns interaction by being given the “space” to have a two-way dialogue. It is through the relationship with you that he learns about how to take and give space to others. This is a process that takes time. The amount of time will vary from person to person. Do not give up on the relationship if it takes months and years to establish the dialogue between you and the autistic person.


• The next step will be for the child to learn to be influenced by another person. This will be difficult to accomplish. For someone who has lived without self-agency, they will have many emotions that could not be expressed. As you work with the individual those feelings will start to be expressed. To be influenced by another person may mean and feel to the autistic person that they no longer have self-agency. They may feel that you are now taking away something that they have worked so hard to get. If trust has been established between the therapist/caregiver and the autistic person than the process of influencing can take place. It needs to be handled slowly and at a pace that the person with autism can manage (there will be future blogs on how to develop space, develop two-way dialogue and how to influence the autistic individual).


• It is important to be creative


• There are no right or wrong techniques, but there are ethical and unethical, legal and illegal techniques.


• The sequence of roles of the therapist/caregiver:
  1. Develop an appropriate frame for therapy
  2. Develop an environment for engagement and attachment with the child
  3. Help the child develop his ability to communicate in general
  4. Help the child identify feeling states within others
  5. Help the child identify feeling states within himself


• The primary areas of focus:
  1. Attachment and engagement
  2. Verbal Level I: nonverbal, echolalia – focus on helping the child develop an attachment and by helping the child find a means of communication, i.e. facilitated communication, etc.
  3. Verbal Level II: the child goes through the following in sequence - you, me, I (when the child can use “you” than you can use projective techniques).
  4. Verbal Level III: Communication of feelings
  5. The time frame that an individual child will take to go through the above areas will vary from child to child.

This blog has been an introduction on how to choose techniques when working with an autistic person. Future blogs will go into more detail about the areas that have been introduced here.

Goal III - Development of a Repertoire of Practical Techniques - Part I

This blog is a continuation of the goals of Relational Therapy. In this discussion I will emphasize how the caregiver or therapist can set out to develop a repertoire of practical techniques while utilizing Relational Therapy with individuals with Autism Spectrum Disorders. Part II of this blog will be a continuation of a discussion of practical techniques that one might use in working with those with autism.

Goal III: The development of a repertoire of practical techniques (Techniques to be used when working with a person who does not have access to use herself in relationship to an other – lacks self-agency)

A. Do not try to extinguish the “behaviors” that the child uses to communicate. This is their only means of communication. This is important for the following reasons: 1) Without the use of oneself, the child exists at the mercy of the other, 2) Without the use of oneself, the child’s body responds to the ‘other’ as if the other controls them, 3) The child is inseparable from the ‘other’ – if the mother says something, the child feels they now have been given permission to exist. This is a very fleeting experience. The child does not have a mind to use with the other. The only thing the child can do is exist as the other. 4) If you do not have any use of yourself in relationship to others, you forget yourself when you are in relationship with an ‘other’. The other ‘other’ becomes like the boss of ‘you’. You cannot make a move unless the other moves first. Your body will not let you move on your own. You are at the will of the other. This is a very good example of being in the waiting position – waiting to attach. 5) Everybody on the outside becomes that “hoped for person” to attach to. Your body acts as if this is the person to attach to and 6) It is important to understand that the child does not have any control over these behaviors or their bodies.

B. Do not force eye contact. As the child can use “I”, the child will use “eye” contact.

C. Interpret the behaviors the best you can back to the child. In doing this, you are letting the child know that you understand what is going on.

D. Understand that the “autistic behaviors” are communications of an unconscious child who uses his body as a means of communication.

E. This type of communication is not nonsensical. It just needs to be understood as one might understand a dream. Also the child talks in metaphor that is like a mystery that needs to be understood

F. It is your job to make meaning of the communication by using words that symbolize the autistic child’s/adolescent’s behavior and or communication. The child does not have the ability to symbolize words and use them as a typical child might. Thus we need to be the intermediary in helping to put words to their actions.

G. All the behaviors of an autistic child are important and need to be understood by the therapist or caregiver so the child can feel understood and recognized.

H. In whatever way you can, let the client know that you see and understand him.

I. The child may or may not let you know that they feel understood.

Next week we will continue this discussion which will include more techniques you can use when working with your autistic child.

Developing an Attachment and Engagement-Part II

This blog is a second in a two part series on attachment and engagement. The following are more of the key points to think about as you develop an attachment with the autistic individual:

1) Compliance by the therapist to the child will be important at first: a) use your knowledge of autism to inform how you use yourself with the child, b) believe that there is a child inside who wants to come out, c) your job is to gain access to the world of the child, d) the child will resist your presence until they accept you, e) The child will allow you to be a presence in their world, f) you do this through play therapy, g) it will be important to join the child in the activities or ‘non-activities’ that they may be doing, h) it may seem like the child is not playing appropriately (unconscious communications that need to be interpreted), but you need to remember that they are doing the best they can, i) as you are with the child continue a dialogue not expecting at first that they will join in. For example, if the child is touching a piece of jewelry you are wearing, do not stop them. Comment something like this “it seems like there is something about the jewelry that you like” or if the child is picking his lips, you might comment “it looks like there is something you are trying to get to”. Interpret all behaviors of the child, i.e. “are you hitting me because you want to be close to me?” You like to run away because you feel free and to have boundaries seems like it is stopping your forward movement of development.”

J) how you approach the child is crucial. It is through your behavior, that the child will allow you to come into their world. At first, this will not be something that you can “see”, but it is a process of earning the child’s trust. The child needs to be allowed to make the internal decision to accept you, k) make a game out of making yourself visible to the child i.e. when Mike ran away, I ran after him. We played a game where he would run and I would catch him. I also made myself present when walking with Mike by periodically stopping and calling to him that I had stopped and asked him to come back to me. Eventually he would and we could have pleasant walks with each other, l) let the child lead the way and as the therapist you become a partner who will not let go of the relationship. Someone needs to hold onto the relationship and it is going to be you because the child cannot hold on to you yet, m) play activities that the child likes, n) you will need to be speaking all the time. Name (symbolize) what the child is doing all the time – for example, you are throwing the ball, I am catching the ball. In a sense you are naming and symbolizing for the child. It may feel like you are talking to yourself, but you need to believe the child can hear you. They just cannot show you they know. If they could, they would be able to use themselves and if that was true they would not be autistic,

o) a constant goal is to understand, validate, accept and recognize the child. This should be in the back of your mind always as you are working with an autistic child, P) teach the child through nonverbal communication how it is to be in a relationship. Much of the early mother/child relationship is based on implicitly learned experiences. For example, we learn how to treat others by how we were treated early in our relationships with our parents, q) echolalia is an example of a child having none to very little self-agency. They repeat back what others say because they do not have ownership of any words for themselves. The only words they have are what they hear. Remember this child is doing the best she can. She is using her environment with whatever means she has. For a child using echolalia, that is the only method the child can communicate at that time in space, r) insist on making yourself present with the child. Do not give up. Remember that you are unconscious to them and your job is to become conscious to the child. Their fear will make this very difficult at first. Do not give up and s) use projection with the child. Remember the child cannot talk and use herself, but she can use projection to talk about herself. In other words she talks by referring to herself as “you.”

2) You are always working with the attachment. This is something that develops over a long period of time. It is a long-term process.
3) It is through the attachment process that you will not only be developing an attachment, but also the child will be leaning to trust you. As this trust evolves, the child will be able to experiment with new behaviors because he feels safe enough to do so.
4) As you are always working with the attachment, there are other specific techniques that you can also incorporate (limited only by your own creativity).
5) At some point, the child will make a decision to attach to you. In other words, the child will allow himself to be influenced by you. He will tell you this by how he allows himself to be in relationship with you. Signs to watch for are – willingness to follow your requests, compliance, talking when they did not talk previously, and use of “me” or “I” versus “you”, pointing at an object or echolalia.

Developing an Attachment and Engagement

This blog is a continuation of the goals of Relational Therapy. In this discussion I will emphasize how the caregiver or therapist can set out to develop an attachment and engagement with individuals with Autism Spectrum Disorders.

Goal II: How to develop a model of attachment and engagement

1) An incomplete attachment causes the child to not have the use of himself. In psychological terms this is called “lack of self-agency.” The degree of agency for each autistic person varies from low to high; 2) The person with autism does not attach as one would expect in “typical” relationships (See previous blog); 3) The work with people with autism is much more difficult than with “typical” individuals. Most therapists at some level identify with aspects of their clients. For example, if you have ever been anxious or depressed, you can empathize with a patient who is anxious or depressed. How you would work with depression with the typical client will seem more straightforward and make more sense than with an autistic individual. With typical patients you might explore their thought processes, and or what happened that might have caused the depression. In other words, you would talk with the client by having a two-way dialogue. People with autism cannot do this. They do not have access to themselves (lack of agency) so they cannot name their feelings or have a two-way conversation that makes sense or is familiar to most. Thus the approach with the person with autism is not clear-cut, but more circuitous and unfamiliar for most therapists; 4) Most therapists do not have a model to empathize with their autistic client. Part of the work with this population is to understand autism so one can develop a means for empathy; 5) It is important also to not expect the same compliance from your autistic client as compared with your typical client. An incomplete attachment precludes working with this population in the same way you might work with a typical client (at least at the beginning); 6) Keep in mind that all “autistic behaviors” are communicating something important for you to understand. (See blog on autistic behaviors).

The following are some of the key points in working with the attachment and engaging with the autistic individual (This section will be broken up into two parts. The second part with appear as the next blog in the following week): 1) First you need to accept that it will be difficult and it will be up to you to encourage the attachment. The child/adolescent cannot be responsible for the awakening of the attachment although the child is ready to complete the attachment process; 2) You will need to go into the child’s world (know the particular child) versus demanding that they accept your world. This is an ongoing part of the therapy; 3) Let your client take the lead. In other words, let the client determine what will happen in therapy even though it does not make sense to you; 4) Use every moment with the child to attach; 5) It may not look like the child is attaching; 6) Do not give up on the child; 7) Always talk with the child as if they understand you and hold onto the belief that they can develop.

The blog next week will continue this discussion on how to gain an attachment with autistic individuals.

Relational Therapy – Treatment (Goals and Application)

The following are goals to incorporate as one conducts Relational Therapy: I) Develop a therapeutic frame, II) Develop a model of attachment and engagement, III) Development of a repertoire of practical techniques, IV) Develop specific steps in deciding which techniques to use, and V) Application through case consultation

I will now take each goal and explain it in more detail in this and the next four blogs.

Goal I: How to develop a therapeutic frame

As with all our patients, we need to follow guidelines in developing a therapeutic frame and boundaries. With this population, it becomes extremely important to adhere to the following guidelines. Not only are we “keeping the frame,” but we are also modeling behavior that the client cannot do for himself. It is important to remember that these individuals feel boundary- less. Individuals with autism may have strongly or loosely held boundaries. Examples of strongly held boundaries would be the lining up of toys, talking about a subject in a sequenced manner or perseverating on a subject. An example of loosely held boundaries would be the child who “seems” to touch others in an inappropriate manner, walks over people or may be a runner.

The following are some suggestions on specific techniques to keep in mind with the autistic population: 1) Be consistent with everything you do – time and place of the therapy. 2) Be dependable. If you agree to do something, do it. Do not promise something you cannot fulfill. 3) Take the child seriously. The child is doing the best he can to exist. He is not being difficult and different because he wants to be. 4) Take your role as therapist seriously. As with all of one’s clients, we need to understand the importance of ourselves to the client. The autistic individuals development depends on you. Think of them as having had an arrested development and that your role is to “jump start their development.” You do this by becoming the person in their world that understands, validates, recognizes and accepts them. Remember that this population has not developed any trust in others so how you interact with them is going to be pivotal to their development. Most likely they will not be able to show you how important you are to them. This is because they lack the ability to use themselves in relationship to you. 5) Be strong and thoughtful about what you say and do. Your behaviors and tone of voice will help to hold (psychologically) or not hold the child. The child is very good at understanding nonverbal communication. In fact for many that is their primary means of communication and will also be the primary means of communication that they will be using to understand you. You provide a holding environment by the strength of conviction you have with the child/adolescent – you need to communicate caring, understanding and a desire to help. It is also important to communicate to the child that together “we will find a way for you (the child) to function in the world. 6) Take responsibility for your actions. The child needs to become conscious of himself in a relationship to you. One way to demonstrate this is to take responsibility for the part you may play in the disjunctions that occur between the two of you. Demonstrate the “repair” process by taking responsibility for your part. 7) Be flexible. One child may need one kind of boundary and another a different kind of boundary. For example, in working with a runner, you will need to run with the child until they can accept you and the boundaries you provide. 8) Do not give up. Be prepared to experiment with different ways of being with the child as long as you maintain ethical standards.

The next blog will focus on Goal II: Developing a model of attachment and engagement.

Core Four of Relational Therapy Continued

The previous blog introduced the Core Four of Relational Therapy. The emphasis of that blog was to discuss the beliefs that are necessary for a parent/caregiver to incorporate when working with Autistic Spectrum Disorders. This blog will address the final two of the Core Four – assumptions and goals of Relational Therapy.

Assumptions that are the basis of Relational Therapy:
A) Relational Therapy is based on the assumption that the autistic child has not had the advantage of an ‘emotional attachment’, B) The child cannot use herself in relationship to others. To expect the child to be able to use herself is like “putting the cart before the horse”, C) A pervasive lack of self-agency means one cannot literally use one’s body, voice, arms or legs – low functioning autism, D) Higher levels of autism can be equated with the ability to utilize dissociation as a mechanism for survival, E) The child is living within the unconscious and thus her behaviors can only make sense if you understand the behaviors as unconscious unvalidated communications, F) There is nothing physically wrong with the child although the child and others feel something is physically wrong, G) What is ‘wrong’ is the delay in psychological development, H) The problem one is working with when working with an autistic child is their psychological development not their physical development, I) We are working with the concept of “Theory of Mind” and not intellectual development, J) Accept the child’s present state of psychological development knowing that it will change. Hold on to the belief that the child will change through the relationship with you. You are trying to forge an attachment, K) It is through an attachment that one can speak when our actions are understood, validated and accepted by another. The ‘other’ through this process, helps the child symbolize their experience. At that point, the child starts to see herself in the eyes of the other, L) The child is in a dissociated state – their intellect is separate from their emotions, M) Savant abilities are an example of a dissociated state, N) Our job is to relate to their emotional states. When this is done the emotional as well as the intellectual part will develop, O) Because the child cannot use herself she will depend on you the professional/ parent to jump start the attachment process, P) The child has no control over her behaviors, Q) The child is ready to attach, but will resist the process (unconscious) because of an original experience of a ‘lack of attachment’, R) The child through the therapeutic process or with the parent needs to have an experience of attachment, S)You are extremely important to the child. The child feels that their life depends on you. From an unconscious perspective, they need you for their development. They do not need just anyone one. They need someone who will be consistent and understanding of their predicament. You become that all-important person to them. That is how important their development is to the child. If you do the wrong thing, then you stop their forward movement. You have to be perfect or at least they need to know that you are trying to do your best. The child will know through your tone of voice and actions how serious you are about their predicament. If they sense you are not serious, then they will not ‘really’ attach to you. That is why it is so important for you to take them seriously. Their development is actually dependent on YOU. They know this and you need to work with them in such a serious way that they believe that you also know this. Also that is why it is so important to understand their predicament. If you do not understand autism from a lack of attachment, then you cannot reflect back to the child that “our presence together is important and what we do together will help the developmental process”. It is the relationship between the two that heals the child and makes the therapist better for having had this experience. Your belief in the importance of your role, the relationship and the child is paramount for the child’s growth. At all times you need to take this seriously. Never let down in your belief in the seriousness of the situation, T) It is important to not take the message of an autistic child from a literal or as a concrete perspective. Autistic children are always communicating on two different levels. The outside communication and the inside communication. Many times, the outside communication appears disjointed or unrelated to what is occurring in the moment. Many of the perseverations of the children are examples of this type of communication. These communications appear confusing to the outside world, but when interpreted properly, in the moment the child feels a sense of understanding that slowly moves the child to forming an attachment with the therapist/parent, U) This attachment process will be slowed down and difficult at best because a basic level of trust needs to be developed with the child, V) The child cannot use themselves in relationship to others and thus you must not expect that they will be able to respond to your requests (lower functioning child), W) Accept that they are existing, but not in the manner you traditionally expect of children, X) You will need to change your frame of mind when working with autistic children – their ability to be conscious about themselves does not exist especially in relationship to others, Y) If they could use themselves they would and eventually will be able to, and Z) You need to hold on to the belief that they can change.

The following are goals to incorporate as you conduct Relational Therapy:

1) Develop a therapeutic frame
2) Develop a model of attachment and engagement
3) Development of a repertoire of practical techniques
4) Develop specific steps in deciding which techniques to use

Relational Therapy with Autism Spectrum Disorders: Beliefs, Behaviors, Assumptions and Goals

Relational therapy is based on understanding autism from an incomplete attachment. It is a therapy that utilizes the relationship as the basis of growth of the autistic child. It is a therapy that utilizes assumptions that the parent/professional believes when interacting with the child. These beliefs/assumptions form the basis of the actual therapy. It emphasizes working with the emotional development of the individual by developing the ability of the child to feel, think about and verbalize their emotions and recognize the emotional states of others (theory of mind). Relational therapy cannot be practiced unless the parent/professional can first accept and adopt important beliefs, behaviors, assumptions and goals. These core four (beliefs, behaviors, assumptions and goals) help form the basis of the worldview the parent or therapist develops in order to work with this population.

This blog will address the first two elements of the core four which are beliefs and behaviors and the next blog will comment on assumptions and goals.

Relational Therapy is based on the following beliefs: a) Acceptance of Relational Therapy assumptions, b) Belief that by accepting these assumptions that one can form a meaningful relationship and attachment with the child, c) Through the relationship change can occur and d) That this change may not only occur within the child but may also occur within the parent/professional (reciprocal).

Relational therapy depends on the following behaviors of the parent/professional:
a) Certain beliefs that must first be incorporated within the parent/professional, b) The development of an emotional attachment between the child and parent/professional, c) The utilization of specific techniques that promote an attachment, d) The desire to experiment with techniques that have never been tried before, e) The acknowledgement that this is a time consuming process, f) The desire to persevere especially when resistance within either of the members of the dyad is very strong, g) The ability to live within the unknown and with ambiguity, h) The ability to not blame the child for the behaviors that they are using because of their lack of attachment (the ability to move from blame to understanding the behaviors as a means of communication), i) The ability to understand that “autistic behaviors” are communications from the unconscious, j) The ability to use one’s countertransference to inform one’s self about the child and the relationship and k) The ability to hold on to hope for an attachment and the forming of a relationship.

Relational Therapy: An Attachment Model for the Treatment of Children, Adolescents and Adults with Autism Spectrum Disorders

The following are questions that are typically asked about Relational Therapy. It is my intent to discuss and expand on the basic concepts of Relational Therapy in future blogs. In the future I will discuss not only the theory behind Relational Therapy, but will explore how to work clinically with clients on the Autism Spectrum.

What is Relational Therapy?

*It is a therapy that utilizes the relationship as the basis of growth (emotional) and development
*It is a therapy based on understanding autism as an “incomplete attachment”
*It is a therapy that emphasizes the development of a SELF/Self agency, and emotional development of the client’s own mind (Theory of Mind)
*It is a therapy that helps the client identify and name their feelings and utilize those feelings in relationship to self and others
*It is a therapy that helps the client to become conscious of his/her own mind when in relationship to others
*It is a therapy that has as a main goal the empathic attunement to the feelings of the client.
*This goal is accomplished by understanding, acceptance and validation of the client’s feelings
*It is a therapy that seeks to “recognize” the client, by seeing the strengths and the potential of the client and in turn for the client to know that they have been seen and recognized by an “other”

What are the Goals of Relational Therapy?

*To develop a therapeutic frame as a basis so that the therapeutic relationship can then be established and expanded to other relationships
*To develop a model for attachment and engagement
*To encourage the client to develop a sense of self-agency
*To develop practical techniques that promote a relationship that generalizes to the environment
*To develop specific steps in deciding which techniques to use with a given client

What is the Population that it serves?

*Children
*Adolescents
*Adults

How is it Different from Applied Behavioral Analysis and other Behavioral Techniques?

It is a psychotherapy based on the relationship between the client and the therapist. It emphasizes techniques to help the child develop a “Theory of Mind.” To help the child move out of the merger position and learn that he has his own mind and to know his own mind. In other words the child learns to identify feeling states within the self, as different from or opposed to that of others, and to utilize his/her own mind/feelings to build a relationship to others. It utilizes techniques to help the developing child to know and interact with the minds of others

On the other hand, Applied Behavioral Analysis emphasizes the systematic process of studying and modifying observable behavior through a manipulation of the environment. It also promotes social and language development and reduces behaviors. It teaches each skill in a simple step-by-step manner, such as teaching colors one at a time. It utilizes formal structured drills, i.e. point to a color and it helps the client to generalize skills to other situations

When should Relational Therapy be used with Clients who are on the Autistic Spectrum?
Relational Therapy is meant to be used in conjunction with other therapies such as Applied Behavioral Analysis, Speech and Occupational Therapy. Each of the other therapies serves a specific purpose, as does Relational Therapy. They are all embraced as needed to enhance the potential of each client with Autism.

What are the Benefits of Relational Therapy?

*It emphasizes the identification of feelings in others and the identification and utilization of the feelings of the client to break through communication barriers
*It emphasizes the development of self agency v merging with the mind of another
*It emphasizes the development of relationships with others including peers
*It emphasizes learning to problem solve “real life situations”
*It emphasizes learning to trust oneself (one’s own mind)
*It emphasizes the building of self-esteem
*It emphasizes the trusting of one’s own judgment

Autism and Dissociation

Through the lens of an “Incomplete Attachment” I have described that the autistic child is experiencing dissociated states. What does this mean? From my perspective, the child has many parts of himself that have not become integrated as a whole. These aspects of the self have not been validated and recognized by “an other” so the child, in turn, cannot use and see himself. Thus the different parts of this child become dissociated and cannot work together to the benefit of the child. We can say that this child does not have the ability to go from one part of himself to another. The child also cannot go within himself to retrieve these dissociated parts.

How can I recognize dissociation in an autistic child? Dissociation is easy to recognize. We all have aspects of dissociation, but it is more profoundly seen in Autism Spectrum Disorders. The following are examples of dissociation: 1) reduced sense of pain – the child may burn himself, but not demonstrate any outward behaviors that say, “I am hurting.” The pain is there and he feels it, but he is split off from his ability to claim it and name the feeling, 2) Exceptional savant skills – such as extraordinary ability to remember days of the week of birthdays and dates associated with events, ability to do mathematical calculations that others can only do with the help of a calculator or great musical and artistic abilities. These abilities seem to coexist with what appears to be severe disabilities. Most people observing such a mixture of behaviors would be confused and conclude that there must be something “wrong” with a person who on the one hand has great musical ability or artistic ability, but cannot talk. I would say this is an example of dissociation in that the emotions are split off from the intellect of the person, 3) Cannot shift thinking from one subject to another – this is an example of not being able to go from one part of the self to another. The individual is demonstrating on the outside of himself what is occurring on the inside of him. In other words, his inability to go from one part of himself to another, and 4) the child can think through mathematical problems, but cannot think through and understand social interactions – the child has access to his intellect, but no access to the emotional parts of himself. The emotional side is harder to access if you have never had an attachment. It is through an attachment that one feels understood and seen and in turn can talk and have access to the emotional parts of one’s self.

These are only a few examples of what I think about when observing the autistic person through the lens of dissociation and an “Incomplete Attachment.” When one thinks about autism from this perspective than one can have hope that the child can develop into an integrated person. The work with the autistic person is to help them to become more conscious of the split off parts. This includes helping them to name their feelings along with the development of a trusting relationship with “an other.” As they become more conscious of themselves their dissociated parts will begin to work together.

Autism and Communication

Getting one’s needs met and to exist happily in one’s family, community and beyond is dependent on the ability to communicate. As non-autistic individuals we can use ourselves to communicate our needs and express our feelings. The autistic individual depending on their functioning level, has anywhere from extremely limited (nonexistent in some) to some ability to ask for their needs to be met. Some people with autism seem to communicate by perseverating on a topic that seems to not relate at all to whatever the topic might be. For example, one child may become fixated on televisions and only be able to talk about this subject, no matter what else is being discussed. It is not unusual for autistic individuals to seem to come out of "left field" with what they might say. For example, the topic may be "going to the grocery store and what will be bought at the store." The child may say, “you are pretty.”

There are also individuals who are nonverbal, those who use echolalia and still others that can only express their needs by reversing their pronouns. When they want a cookie to eat, instead of saying “I want a cookie,” the child may say, “you want a cookie.”

Let’s make sense of what is going on. If as I am suggesting the child has not had the benefit of an attachment, lacks the ability to use him/herself in relationship to others and is also in a state of dissociation with varying degrees of consciousness then I would continue to propose that the child’s ability to communicate is going to be compromised. Let me explain how these different elements contribute to not only problems in communicating, but also relating to others.

It is important to remember that the autistic individual wants to communicate and in fact is always communicating about himself even though he may be nonverbal, echolalic or reversing pronouns. He is like any human being in that he has a need to communicate. Unfortunately, because he has had an incomplete attachment, he cannot identify his feelings, which are dissociated, and therefore cannot use those feelings to express his needs. In other words, he has not developed to a level where he has self-agency. This means he literally cannot ask for anything for his own benefit. This is not a physical problem, but instead a “developmental problem” that can change over time.

It is my opinion, that what one sees with the nonverbal autistic child is the reverse of what one sees with a “typical” child. I call this phenomenon “Inside out, upside down.” In other words, the unconscious part of the child is on the outside and the conscious part is in the inside. That is why some nonverbal autistic children seem out of control and low functioning, but with the use of a computer can communicate beautifully in writing. This is a very good example of the split or dissociation of the self. Most people are unfamiliar with seeing the ‘unconscious.’ Because most people are unfamiliar with the workings of the unconscious, autistic individuals are constantly misunderstood.

The phenomenon of echolalia is also something that can be understood. One first needs to remember that the autistic child has minimal and varying (depending on their functioning level) ability to use oneself in relationship to others. Also it is important to remember that a lack of attachment precludes one from being able to use one’s self. Thus echolalia is the result of not being able to use one’s self. The child only has access to what they hear. They may hear “do you want a cookie?” Developmentally all the child can do is mimic the other person. There is no awareness and ability to use the self in response to the other. Thus the end result is a repetition of what the child heard.

The child who reverses his pronouns and uses ‘you’ to mean ‘I’ is beginning to use his self with others. The child uses ‘you’ because it is safer than ‘me or I.’ The autistic child does not feel safe in the world. Everything is confusing, awkward and anxiety producing. The use of ‘you’ as it refers to the self is another example of dissociation. As I mentioned before the child is split. As the child develops and he becomes less split and gains more agency, he will then move to using the pronoun ‘me’ and finally as he has more and more access to himself, he will be able to use ‘I.’ There seems to be a direct correlation to the use of ‘I’ and ability to know and access feelings and use them in relationship to others.

Now lets look at why the communication of autistic individuals appears inappropriate. First of all, I believe that an autistic individual is always communicating his state of existence. Unfortunately, most perceive these communications from their own experience, which includes having completed the attachment process. In working with autistic individuals, many try to extinguish the “odd” behaviors of the child. In doing so, we are not understanding the message the child is trying to communicate through his strange behaviors. We in a sense are helping them feel misunderstood versus understood and not seen versus seen. Instead these communications need to be understood within the context of a child who has never attached and cannot use the self to communicate. Every behavior that the child uses can be understood and must be understood so that the child can gain understanding and recognition, which are precursors to being able to attach. Our work with the autistic person is to understand, validate, accept and recognize the autistic person. If the caregiver or professional can recognize and see the child, then the child can start to see him or herself.

Examples may help you to understand what I am communicating. I visited a three-year-old nonverbal boy, who had never seemed to play appropriately with his toys. In observing him, I noticed he was picking his lips. Instead of telling him not to pick his lips, I said, “you are telling me that something is going on around your lips and your inability to talk.” He looked at me and then played appropriately with a toy. Another example will help to highlight this point. I worked with another boy who liked to watch videos. He had certain ones he wanted to make sure I saw. One day, he showed me a video, which explained a complicated family dynamic. I interpreted the dynamic as it related to his family. As I was able to do that, he could begin to talk about his own personal experience. These are examples of how one interprets and uses projection with autistic individuals to gain access to their feelings (I will discuss how this is done in another blog).

In concluding this blog, I want to restate that the perseverations, the out of context communications, the use of pronoun reversal, echolalia, nonverbal communication, to name only a few, can be understood through the lens of an “Incomplete Attachment” which leaves the individual in a state waiting for the completed attachment and without access to self or what I call self-agency.