Thursday, November 26, 2009

“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.

Saturday, November 21, 2009

“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.

Wednesday, November 11, 2009

“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.

Thursday, November 5, 2009

“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.