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.

Play Dates and the Autistic Child

The desire to have one’s child interact with and to be accepted by others is the wish of all parents. When this does not occur the parent may become concerned, anxious or worried. Parents of autistic children face this dilemma on a daily basis. They are very aware that their children interact differently and display behaviors that are confusing to most.

The autistic child’s ability to interact and engage with others is limited and varies on a continuum from complete noninvolvement with others to sporadic and limited involvement. For the autistic child involvement with others can be confusing, intimidating and frightening. Autistic children can benefit positively to the exposure to other children through play activities.

Some suggestions to consider in setting up play dates:
· Begin slowly and with patience. First, have a conversation with the parent of the child you want to set the play date with. Come up with a simple way to educate the parent about your child’s behaviors and your desire to have the two children play. If the parent is receptive, the next step is to talk with the non autistic child and parent together about your child’s desire to play. Next talk to your own child about your intention;
· Set up the play date in your home. Your child is familiar with this environment;
· Limit the time based on your child’s ability to be with others. I would suggest a half hour. Decide on an activity that you know that your child can engage in. Supervise the two children in the activity. If they seem engaged let the children continue the activity under your watchful eye;
· At first parallel play may be all your child can tolerate;
· You may want to have multiple activities available if the children do not respond to the initial activity;
· Leave time for cleaning up, a story and refreshments;
· Continue with short play dates, but increase the time with others as your own child can tolerate longer interactions;
· After the play date you may want to check in with the other parent to see how her child handled the play date. If things went relatively well, you may want to continue such interactions. It is important to have a willing other parent and child that feel comfortable in supporting these activities.

As a point of caution, do not give up. This will be a slow process, but one that can be rewarding for all involved.