Psychotherapeutic approaches to helping adults with intellectual disability and autism spectrum conditions

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DSM-5 is likely to provide a dimensional approach to ASD with two main dimensions: social communication disorder, and repetitiveness. ID/ language impairment adds a further dimension. I shall start my talk with a consideration of how a psychotherapeutic orientation can be relevant to these neurodevelopmental dimensions as well as associated neurodevelopmental disorders, particularly ADHD. However, the main value of a psychotherapeutic approach is in relation to the emotional difficulties associated with ASD and ID, and I shall consider particularly the consequences of bullying, exploitation, and marginalization with special attention on the management of anxiety and of seeking to make an impact on others.

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Psychotherapeutic approaches to helping adults with intellectual disability and autism spectrum conditions

  1. 1. Psychotherapeutic approaches to helping adults with intellectual disability and autism spectrum conditions Digby Tantam, Septimus Ltd., Universities of Sheffield, and Cambridge22 May RSM2012
  2. 2. Further information
  3. 3. Autistic syndrome Restricted repetitiveness (DSM-5) Impaired social communication and social interaction (DSM-5) Language impairment22 May RSM2012
  4. 4. Associated conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5) ADHD Tourette, dyspraxia, agnosias Intellectual disability Language impairment22 May RSM2012
  5. 5. Consequential conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5)Sensory issues, ADHDInformation overload,melt downsAnxiety-related disorder Tourette, dyspraxia, agnosias Victimization Marginalization Intellectual disability Language impairment The search for the self22 May RSM2012
  6. 6. General principles of psychotherapeutic work in ASD•  Do not expect narrative awareness or autobiographical memory•  Do not rely on signs of attention•  Simplify language but not ideas•  Look for other communication media•  May be easier to translate and then respond in action e.g. change carer behaviour than to communicate•  Role blurring –  Advocate –  Advisor –  Carer 22 May RSM 2012
  7. 7. Autistic syndrome Restricted repetitiveness (DSM-5) Impaired social communication and social interaction (DSM-5)Enter the other’s world, butdo not expect intersubjectivityBe aware of the importance of the past and look forcommemorative activitiesProvide predictability (may achieve this throughbehavioural means e.g. ABC approach)Be aware that anxiety—and frustration– may not beexpressedDo not assume that a lack of social interaction is a Language impairmentlack of interestValue peer support 22 May RSM 2012
  8. 8. Autistic syndrome Restricted repetitiveness (DSM-5) Impaired social communication and social interaction (DSM-5)Consider sameness to be a means of achieving comfort throughpredictabilityAn increase in repetition may indicate anxietyAn appropriate balance must be struck about how much comfort isappropriateRituals may be commemorative and acts of iImaginativereconstruction that are open to involvement and modification by kindlyothersSpecial interests provide quality of lifeOCD and hoarding involve an additional element of folie de doute, orwarding offRituals may come to be weapons Language impairment 22 May RSM 2012
  9. 9. Autistic syndrome Restricted repetitiveness (DSM-5) Impaired social communication and social interaction (DSM-5)Language, verbal IQ, and intellectual disability are correlatedAlternative means of communication may be usefulPeople with ID may develop simplifying concepts that can beeffective tools e.g. the open and closed faceWritten language may sometimes be more comprehensibleProcessing may take longer, but get there in the endApparent verbal fluency may be deceptive: it’s understanding notlanguage that mattersPsychotherapy may be a matter of connecting the dots… Language impairment 22 May RSM 2012
  10. 10. Associated conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5)Learning from the EE literature ADHDUnderstanding impersistenceCueing attention Tourette, dyspraxia, agnosiasDysexecutive Autistic syndromeHow does Dad handle it? Intellectual disability Language impairment 22 May RSM 2012
  11. 11. Consequential conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5) Sensory issues, Meltdowns are catastrophic reactions. ADHD Information overload, melt downs They can only be prevented when tension Is at an early stage but may then be unrecognizable unless individualAnxiety-related disorder prodrome is known Tourette, dyspraxia, Victimization A sensory assessment may be helpful, agnosias Include but should information demands Marginalization Intellectual disability Language impairment The search for the self22 May RSM2012
  12. 12. Consequential conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5)Sensory issues, The risk of a person with an ASD being bullied is ADHDInformation overload, 7 times greater relative to the risk of a neurotypicalmelt downs child of the same ageAnxiety-related disorder Tourette, dyspraxia, agnosias Victimization Marginalization Intellectual disability Language impairment The search for the self22 May RSM2012
  13. 13. Consequences of bullying•  Passive failure to be included –  Reduced use of community resources (social exclusion) –  Experience of being unwanted/marginalized•  Active rejection , blaming, scapegoating Painted Bird by Edward –  Stigma as a means of Gafford, inspired by the keeping threatening novel ‘Painted Bird’ by Jerzy Kosiński, itself Other at a distance based on what has been –  Bullying claimed is a fictive war- time experience of the author in Poland
  14. 14. Consequential conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5)Sensory issues, ADHDInformation overload,melt downs Making an impact:uproar, aggression, weaponizingAnxiety-related disorder Containing the risk so that non-reinforcement is Tourette, dyspraxia, possible agnosias Victimization Marginalization Intellectual disability Language impairment The search for the self22 May RSM2012
  15. 15. 22 May RSM2012
  16. 16. Consequential conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5)Sensory issues, ADHDInformation overload,melt downs Identity borrowings Anxiety-related disorder Providing a healthy identity Tourette, dyspraxia, agnosias Victimization Marginalization Intellectual disability Language impairment The search for the self22 May RSM2012
  17. 17. Coping with a lack of identity•  Fads•  ‘Obsessive’ relationships•  Lack of identity in many people with ASD –  Adopting identity wholesale –  Joining charismatic groups –  Moving places and work•  Searching for identity –  ‘Transexualism’ –  ‘Aspie’•  Identities off the peg –  Gangster –  Professor –  Teddy bear 22 May 2012 RSM
  18. 18. Consequential conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5)Sensory issues, ADHDInformation overload,melt downs Anxiety-related disorder Tourette, dyspraxia, agnosias Victimization Marginalization Intellectual disability Language impairment The search for the self22 May RSM2012
  19. 19. ‘Proper’ psychotherapy•  No particular modality is better than another, although person- centered is good•  Limited value for CBT (assumes ‘lexithymia’)•  Do not expect working through•  Social predicaments are relatively less common than in general psychotherapy•  Ruminations may be an issue –  E.g. issues of injustice•  Misunderstandings may be an issue –  E.g ‘You’ll be the death of her”•  May require the reconstruction of another person’s perspective Practical advice may also be required•  22 May RSM 2012
  20. 20. The end. Thanks for listening. Slides at www.22 May RSM2012
  21. 21. Consequential conditions Restricted repetitiveness (DSM-5) Impaired social communication and social interaction Epilepsy (DSM-5)Sensory issues, ADHDInformation overload,melt downs Tourette, dyspraxia, agnosias Victimization Marginalization Intellectual disability Language impairment The search for the self22 May RSM2012

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