Thursday, June 18, 2009

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

Thursday, June 11, 2009

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.

Thursday, June 4, 2009

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?


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