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My client is on the spectrum! Now what? (I)

What my client is saying reminds me of an article I read about the autism spectrum! thinks the psychologist. My client's complaint descriptions seem to fit the autism spectrum, although I'm not sure! thinks the psychologist.


Don't think that psychologists don't have questions, doubts and even fears, because they do! And yes, this also applies when we receive certain consultation requests which, for various reasons, may seem to be more challenging clinical situations. But what is certain is that people need help and an answer to their questions.


Hello, how are you? I need your help. I think I have a person in consultation who may be on the autism spectrum. I need to talk to you so I know what to do! it said in the message I received from a friend and colleague.


After a brief initial conversation with this colleague of mine, the issue of heterogeneity present in autism arose. And since this is a fact, I mentioned that heterogeneity is in autism as well as outside autism. That is, we find less and less people in the clinic whose situation fits only and exclusively into one single diagnosis. And increasingly we find that the presence of other diagnoses in comorbidity or traits of other conditions is more frequent. And this mainly to help demobilise some resistance towards autism, the complexity of this diagnosis and the challenges that can be anticipated. At times, professionals may feel immersed in what we hear about the variability present in autism. As if this variability in autism is synonymous with not being able to know or understand what autism is. And when there seems to be a greater focus on this aspect we may run the risk of deviating from the person, from his identity.


So, when you are talking to a client and you wonder if he is autistic, do not try to observe only his behaviours or difficulties. Try not to stick to autism from a categorical perspective. Even though it is understandable given the very pressure that diagnostic manuals and others cause. Ask about experiences. That's right, ask the person to tell you about how and what have been his/her experiences throughout life and in specific moments. If you want to know autism from the inside, do so mainly by listening to autistic people's own experiences, the way they live their lives and make their decision-making. Or try to simply listen to what autistic people say when they share their experiences and way of understanding the world and themselves on social media. This way you will be better able to progress beyond the stereotypes and know the right questions to ask. And most importantly you will be creating a safe space for the autistic person.


In the last few years, the autistic community itself has been transformed and now consists mostly of autistic people, and not only of parents and concerned health professionals. What is certain is that there has been a lobby of the autistic community that has tried to draw the attention of the clinical and research community to other equally important aspects. And the clinical and research community itself has also tried to reflect and evolve about the questions to be asked and the very methods of intervention and research to be used. An example of this is the greater variety of intervention programmes which do not focus exclusively on the ABA model or on Behavioural and Cognitive models (CBT). But also in research, where research designs have been increasingly qualitative, or the very instruments used for screening and diagnosis seem to reflect more and better the reality of autistic people, namely in adult life.


Besides these aspects, the epidemiological studies carried out have shown a higher prevalence of Autism Spectrum Disorder cases. This does not mean that cases of autism are increasing, as has been asked. The change in diagnostic criteria, greater reliability of diagnostic instruments, awareness of the clinical community and of Society, among others. All of these have contributed significantly to the results found. One in every fifty-four cases has a diagnosis of Autism Spectrum Disorder. And as adults are increasingly informed and aware, they themselves have sought an intervention response to their clinical situations and needs. And also because of this, the different health professionals have received more and more requests of this nature, either to assess/diagnose or to intervene. And bearing in mind that in different countries, although with different realities, the public health system has shown little capacity to respond in evaluation/diagnosis and also in intervention.


But it is not only these aspects that have changed. Given the fact that more and more autistic people themselves, whether formally diagnosed or self-identified as such, are becoming more demanding in relation to intervention responses. And I say - Good! In other words, autistic people no longer want only a change in certain behaviours, even though this is important in certain aspects. They don't just want to be more functional. More and more autistic people say that it's OK to be autistic. On the contrary, they are proud of being autistic. And as such they do not seek psychotherapy for change, but for understanding, which in fact also necessarily leads to change.


But then, what are the clues that could help alert my colleague to the possibility that his client might be autistic?


In the case of this person being young or adult, do not assume that the person is unaware about autism. A significant number of people who suspect they are on the autism spectrum and seek this assessment or even follow-up have already sought information about the diagnosis and also about the intervention itself. And as such, it may be important not to ask questions anchored in what are the main diagnostic criteria and which are very present in screening questionnaires, such as the Autism Quotient Questionnaire (AQ). And many of these people have already completed this and other questionnaires online. So it might be a good option not to ask if they're fascinated by dates, or if they'd rather go to a library than a party. Or if they are more attached to things than people. You might hear your client talk about sensory sensitivity (e.g., sounds, smells, scratchy clothes, bright lights). Or they may seek out certain sensory stimuli (e.g., soft fabrics, heavy blankets, cold water). They may have a consistent sense of difference, which can be traced back to childhood. They may comment on their slow processing speed, despite the fact that they have average or high intelligence, or refer to perceiving the world as bewildering, or to consistent misunderstandings.


They may be aware that 'being themselves' is often disastrous, so they feel they are constantly masking, camouflaging, imitating others in order to look or behave 'correctly'. They may notice a tendency to see details rather than the whole. They almost certainly have an intense focus on specific interests and these can vary in a wide range. Many autistic people have problems at school or at work and that is related to their profile but also to the lack of knowledge of people in the context in relation to this profile and what autism is.


The idea is that Autism Spectrum Disorder needs to be looked at beyond the diagnostic criteria present in the diagnostic manuals. These are important, but they are not the only ones that matter. This is because the criteria, as they stand, do not consider a fundamental part of the autism spectrum. In addition to not reflecting at all the phenotype existing in women. It is also necessary to remember that although we talk about autistic people or people who seek diagnosis, they are people. It seems strange to have to remember this but it seems fundamental. Even because some of the intervention proposals seem to look at the autistic person as being compartmentalised in behaviours and that these behaviours should be objectified and changed. As if the identity of the person itself were not fundamental and basic in the whole process. I will return to this theme, also because the changes in all the intervening parties and in the psychotherapeutic process itself are undergoing transformations.


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