Thursday, July 30, 2009

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.

Thursday, July 23, 2009

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.