This blog was written by Dr Francesca Sawer. For further information about Francesca, please click on ‘who we are’ or make an appointment with Francesca by submitting an enquiry form.
I am fortunate that a large amount of my work as a Clinical Psychologist includes working with children and teenagers who have a diagnosis of autism. Yet it still surprises me how many people I talk to (including other professionals) have misconceptions about what therapy for people with autism is, or looks like in practice.
So here’s my experience of what psychological therapy for people with autism is:
1) It is the same as therapy for anyone else
So firstly and most importantly, my opinion is that therapy for someone with autism is same as for anyone else who walks through my clinic door, albeit with some adaptions in order to suit to strengths and thinking style of the person. But I would always adapt therapy for anyone in that way anyway.
2) I am not “treating” autism
Autism is a neurodevelopmental condition; a difference in the way a person sees and interprets the world and not something which is curable or should ever be seen as something that needs fixing. Instead I am working with the difficulties that often co-occur alongside autism and most commonly this is social anxiety, worry, managing distressing emotions and angry feelings, navigating friendships, learning to manage change and uncertainty, developing social skills and building self-confidence alongside acceptance and understanding of the autism diagnosis itself.
The length of time it takes for a person to trust you is different for everyone, however my experience is that it takes a little bit longer for young people with autism to feel comfortable with me. Therefore the first few sessions are primarily focused on engagement and helping a person to feel safe with me. It can be uncomfortable for a therapist to spend a session saying very little or talking solely about a person’s interests (and not “sticking to an agenda or plan”), but if this is what is needed to bring down anxiety and build rapport then this is essential for the success of the rest of the therapy.
My experience of working in the NHS is that it can also be particularly hard to justify spending some of your allocated sessions “engaging and getting to know your client”, but personally I think it is short sighted to not see the value in this, given the huge benefits it has on therapeutic outcome. For example I once spent an entire session walking round the park with a young girl who found it too overwhelming to come inside and this was far more benefit than triggering a meltdown or sending her home and reinforcing a feeling of failure, that we were so desperately trying to challenge.
In my earlier days working as a Clinical Psychologist I also remember spending the first 5 of 20 sessions using back and forth written exchanges with teenager whom found it too overwhelming to talk, but who could articulate his experiences beautifully in writing.
4) Interest and special interests
Many young people with autism have a particular interest which is personal to them and I always try to use this creatively in my therapy sessions. Whatever the interest, I will take some time to learn about it and incorporate it into the therapy. This also has additional benefits in that special interests can be a great distraction during times of distress and also talking about these can help to build the therapeutic relationship.
For one young boy with a special interest in Eminem we spent some time each session listening to his favourite Eminem songs and then part of his therapy involved him writing his own rap song about his emotions and the ways he learnt to express and manage them.
I also worked with a young person with an avid interest in Harry Potter. We worked together to develop spells (essentially coping strategies) which he could cast when he felt particular emotions e.g. “The Breathing Spell” to cast at anxiety and “The Transformation of the Angry Wolf Spell” to cast at anger.
5) Visual resources
For many people (with and without autism) it can be easier to process information visually. Therefore handouts, visual resources and visual timetables (which lead the young person through the session) are often a great addition to the therapy. They are also a good way of sharing your sessions with the wider system so that families and school can also learn about the strategies the child is learning, so that ideas can be reinforced at home and in the classroom. They serve as a great reminder of the therapy too, so that the young person can continue practicing the skills they have learnt when their therapy has finished.
6) Involve the system
A young person can only do so much by themselves and if the environment they are going back to (home and school) remains the same then how can we expect their changes to be sustained? As a Clinical Psychologist I always consider how the system may be working with the child and where possible make sure that I consult with parents (and school if necessary) to think about anything else which could change in the wider system to make it easier for the young person. This also reinforces a really important message that the young person is not to blame for their autism and that the system around the young person also needs to change and become more accommodating.
7) Promoting flexibility through behaviour change
Young people with autism may be more “rigid” in their thinking. They see the world in a much more concrete and literal way, making it challenging to see the other options. Cognitive challenging and restructuring are tools that therapists are very familiar with and which have a good evidence base; however my experience is that these techniques are less effective when working with autism. Instead, rather than cognitive challenging I focus on demonstrating change and flexibility through behaviour, for example I encourage the person to walk a different way to the session, to wear a different T-shirt, or switch chairs, then I highlight that a change just occurred and help the young person to experience for themselves (rather than imagine) that there are alternative ways of doing things/seeing things. I have also learnt to complete any behavioural experiments across different settings and contexts because people with autism may find it harder to generalise. Just because they effectively used a strategy in the therapy room it may not be obvious that this same strategy can also be used at school so this needs to be made explicit to the young person.
8) Be accommodating for sensory sensitivities
People with autism may be particularly sensitive to sensory stimuli (light, sound, touch etc.). For some people this is a under sensitivity and for some people this is an over sensitivity. I have learnt that it is important to be mindful of this when you meet with the person and you can do very simple checks to reduce sensory sensitivities for example, checking that the lighting and sound is okay and having options of more or less light/sound (e.g. dimmer switches and options of light background noise such as a radio/white noise).
I have also found it helpful having a range of sensory stimuli and toys to hand for calming during times of emotional distress e.g. soft blankets, fidget toys, stress ball etc.
9) Strengths, skills and struggles
Therapy is often focused around struggles and on changing the things that a person finds difficult. Whilst no one would disagree this is important, I strongly believe that it is also vital to highlight a person’s skills and strengths and build a positive narrative around these, so that the young person develops a message of survival and coping going forward after the therapy. Let’s not forget the autistic mind is an amazing mind which has brought us the likes of Isaac Newton, Bill Gates and Albert Einstein, so we need to find the persons strengths and develop these so that they can go forward and onto great things!
10) Be directive
Being directive should not be a substitute for collaboration; however as a Clinical Psychologist I am trained to be ‘Socratic’ and guide a person to find the answer for themselves by asking a series of questions which might lead to this answer. Generally I have found that when working with people with autism this approach doesn’t work and that young people either start guessing what they want you to hear or look at you with bewilderment. So, I recommend avoiding the metaphors and open ended questions and instead being direct in your intentions and questions.