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.

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.

Relational Therapy and an Incomplete Attachment: A New Look at the Etiology and Treatment of Autism Spectrum Disorders

Autism is like being trapped in an enclosed maze. Within this maze it is dark and scary. You can see out, but no one can see in. You are in a perpetual state of terror with no access to others or a way out. You feel the walls closing in and can do nothing about it. You are screaming inside, but nobody can hear your screams. You are frantic. You keep running in circles to no avail. Alas you run out of steam. It is futile, hopeless and depressing. It is no use. No one can see you. You have become a lost child forever. You have become forgotten. Lost in a never-never land. It is a never-ending hell on earth. The only thing you can do is wait and hope that you will be discovered.

Mystery and controversy surround the etiology and clinical work with children diagnosed with an Autism Spectrum Disorder. Although the etiology by many is considered to be unknown, the majority of professionals working in the field of autism and parents of autistic children consider autism to be a neurological disorder. From this perspective, the clinical work with this population focuses primarily on techniques such as Applied Behavioral Analysis, modeling and social skills development. The work done thus far with this population should be commended and not discounted. We are now ready to augment the present state-of-the-art work with this population by introducing Relational Therapy. This therapy is similar to Floortime in that it emphasizes the relationship between the child and the therapist or caregiver. The major difference is that Relational Therapy introduces a treatment process (plan) that at its core is based on understanding the etiology of autism. Once the etiology is understood, then the therapist or parent can understand how to engage with the child.

From this alternative perspective it is my belief that children on the spectrum have not had the advantage of a completed attachment. I call this perspective “Incomplete Attachment.” Thus it is my belief that what one sees when observing children on the spectrum is a child who is waiting for the attachment process to be completed. The child is doing the best he/she can to cope with this predicament. All the behaviors such as flapping arms, nonverbal communication, echolalia, lack of responsiveness to others or inability to communicate one’s needs, can all make sense when taken from this perspective.

These writings will go into detail about this perspective and how one works with children, adolescents and adults from this perspective. It is my belief that Autism Spectrum Disorders can also inform our understanding of psychological development in general and specifically Theory of Mind. Autism Spectrum Disorders can be viewed as a window into the understanding of how all “typical” individuals develop psychologically. It is my hope that these writings will lead to a beneficial dialogue within the autism community and beyond.

As a point of reference, I am presently working as a marriage and family therapist in West Los Angeles. I specialize in Autism Spectrum Disorders, depression, anger management, assertion training, anxiety and primitive states. I have worked for many years with children, adolescents and adults on the autism spectrum continuum. I have also provided trainings and support groups for parents of children with autism. I am now running groups for college age students with developmental disabilities. And finally I have made presentations on this subject at numerous conferences and meetings.

My next blog will discuss the Incomplete Attachment in more depth and begin to discuss the meaning of “autistic behaviors.”