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My client is on the spectrum, now what? (II)

Last week I wrote the first text on this subject, My client is on the spectrum, now what? (I) - see here. And as I had mentioned, implicitly and explicitly, there are a whole range of other issues that need to be thought about.


I feel that a fundamental issue and one that can bring a great challenge for many of our psychologist and psychotherapist colleagues is the question of the therapeutic relationship or therapeutic alliance. And even more so when thinking about this one with a client with a diagnosis of Autism Spectrum Disorder. And if we think about the importance of the therapeutic relationship for the effectiveness of psychotherapy, the client's change process and the achievement of therapeutic goals, this question becomes even more important to reflect upon.


But how does a psychotherapist establish a viable therapeutic relationship with a person whose profile of functioning is based on the unique way in which he understands social relationships and becomes involved in them in his daily life? The question is not only about knowing how to diagnose an Autism Spectrum Disorder anymore. Or that this diagnosis is not limited exclusively to the characteristics listed in the DSM. Or that there are numerous other psychiatric conditions associated with this diagnosis! We are talking about how do we relate in therapy with an autistic person? And how can we, as psychotherapists, contribute to the emergence of this therapeutic relationship and how can it grow and consolidate to become a transforming instrument? And when we receive adult autistic people we must think that they may have been taken to countless consultations for some time and that in many of them they have not felt accepted or even understood in their nature. Or they did not even understand why they were taken or even wanted to go! Not to mention those who have also been to countless consultations of their own free will and no one ever told them that they might be autistic.


But then, what do we have when we talk about therapeutic relationship or therapeutic alliance? We can think quite simply that it is about the relationship that is established between the psychotherapist and his/her client. And that this interpersonal relationship is dynamic and emerges in the context of psychotherapeutic intervention. And that it refers to the collaboration between these two people for the change of the client. And it will be to a large extent this relationship and the way in which it is consolidated, which will contribute to the client's process of confidence in the changes he will undergo, whether these be internal or external. The therapeutic relationship is a preponderant factor in the results obtained in therapy and this same impact is observed in different models of intervention. Moreover, the therapeutic relationship does not end with the establishment of the relationship per se. It has itself different and diverse aspects contained within it, namely the therapeutic alliance, that is to say, the agreement existing between the psychotherapist and the client in relation to the objectives to be reached, tasks and the feeling of the bonds created.


When I think of this aspect of the therapeutic relationship, I often recall the question I initially asked my supervisor when I was doing my internship - How to deal with silence? And oddly enough, he would send it back to me! To which I was frustrated, I confess. I really wanted to know how to deal with my client's silence. And he wanted to help me think and feel about what it was that I felt inside me with the silence my client brought to the session. What did it mean for me? he asked me. What do you feel in that moment when the person was silent? he continued. And what do you think it might mean for the psychotherapeutic process? he continued. The questions were many and they contrasted with the silence of my question. It was a path that I needed to follow and that I am still following today. But why did I take up this issue of silence? Because it is something we often find in the psychotherapeutic process with autistic people. And no, it does not necessarily mean that the autistic person has nothing to say or is not feeling anything.


Can I start by saying something? she asked me as soon as she entered the room and sat down. I answered him yes. You know, in the same way that I feel that people are not prepared to accept my true nature. I also feel that psychologists are not prepared to understand me! I said it all at once. The sentence seemed to have been said at other times, as if it had been rehearsed. But I felt that all of it was genuine. When I shared the situation in supervision and was asked how I felt I didn't know what to say for a few minutes. Someone said - Scared? Assaulted? No! I replied. I wondered what the person had experienced in other consultations for saying similar things. But on the way home I kept thinking that some, I don't know how many psychologists and psychotherapists, may feel frightened, assaulted or something similar when these or other phrases are said.


Before giving me an answer, may I tell you something that really affects me? he asked me. Yes, of course! Don't tell me that you feel, know or understand what I am feeling! The last time a colleague of yours said this I asked him how he knew it if it was not inside me. I don't think he could answer that! he said.


Before you start talking to me about autism, let me say that I have read everything there is to read on the subject! he said while I was inviting him to sit down. Everything concerning the Theory of Mind and other similar theoretical aspects I have already learned. That's not why I came here, but to understand myself, you understand? he asked me.


Don't tell me that you can help me, because I don't even know what I want! he told me. Very often a person doesn't know what to say in a consultation. Not because they don't have anything to say - because they do. But also because they don't know what to say and what makes sense to say or what the psychotherapist would like to be said. In any case, the autistic person has a lot to say. And it is fundamental to be facilitators of that talk. And, for that, we also need to deconstruct some ideas we have been building about being a psychotherapist. It is necessary that the autistic person feels and perceives that what is being said or what he is expected to say may make sense to him. That is, in the therapeutic relationship, an important aspect to be taken into account is the client's desire to share things with the psychotherapist. But this will be different depending on the person we have in consultation. And this can and should also be understood with the autistic person. And we may have the ability to think that this aspect may have different configurations from those people we may be used to receiving in consultations. And there is nothing wrong with that, it is simply a different way. Just like the aspect of the autistic person establishing a relationship with us in the consultation. A relationship that implies a whole set of affections and feelings involved and that should be configured in a different way from those relationships that people, all of them, are used to developing in daily life. And also when defining together the therapeutic aims, it may and should be considered that the autistic person may have an opinion, sometimes very different from the one the psychotherapist has. And as much as this observation may not make sense, I call attention to what has been said more and more about the behavioural changes proposed to autistic people in therapy and which for more and more autistic people does not even make sense, besides being seen as something aggressive. I can give for example the stimming behaviours.


And many of these and other situations may be felt by the psychotherapist as a lack of adherence of the autistic person to the therapeutic process and to the change itself. Reason which ends up leading directly or indirectly to a reaction in the psychotherapist. And, in case it may be more reactive and negative, it may be interpreted by the autistic person as an unavailability in the relationship. And most probably, the autistic person will not say that in the consultation, which may lead to it not being possible to be worked on. And all this will certainly contaminate the relationship and may lead to a feeling of ineffectiveness of the process and lead to abandonment, for example.


A good way to start a good therapeutic relationship is to know about the internal experience of the person. Many psychologists reading this may think that this is what is learned in Psychotherapy I. Which is true, but it is necessary to adapt this notion to the person we have with us. And, in the case of the autistic person, he may need help to understand what this inner experience means. And the explanation does not or should not be done in an academic way, but in a way that makes sense to the person.


But the possibility that the autistic person has come to a consultation because someone told him to is not to be ruled out. In other words, the person him/herself does not feel the need for that consultation request. Even because the way he or she feels his or her needs may not necessarily include this request. Which does not mean that the person is not suffering!


I don't remember having emotional empathy at any time in my life, and I believed that this would be my reality forever! Why, because I am autistic! For a long time, I had forgotten that my life started with a trauma because I slept badly from the age of four months. Or that I needed a syringe to be fed by my parents for three years. I still remember that syringe to this day. I experienced similar things again during school with some of my classmates. Whether it was because they teased me or because I didn't understand them and neither did they! I felt like a ghost among the living!


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