Thursday, August 27, 2009

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.

Thursday, August 20, 2009

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.

Thursday, August 13, 2009

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.

Thursday, August 6, 2009

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.