How important are relationships in the lives of people with autism?

Studio 3 clinician Dr. John McDermott discusses relationships and autism, and the role played by the emotional and relational world when supporting clients.

The importance of relationship in the lives of people who have an autism diagnosis is a crucial part of our practice at Studio 3. When working therapeutically with clients, parents or caregivers, we aim to capture individual client meaning and what they might need from the people who support them. In psychology we refer to such approaches as systemic in the sense that rather than looking at just the individual, we recognize that the whole system around the person has impact on well-being. The professional literature talks of the problem of the “identified patient” in therapy, and how we must be careful not to focus on individuals while ignoring the other humans in their lives. Such systemic approaches also acknowledge that it can be unfair, unhelpful or even unethical to focus on behavioural approaches which attempt to change the behaviour of the person who has an autism diagnosis.

When working one on one with clients in therapy, I am moved by the importance they and their families attach to their relational and emotional world, and the powerful grip that emotional experience has on their lives. Client stories have directed my professional focus towards the emotional and relational impact autism has on the lives of clients and their families, and the resulting distress or “trauma” held in family systems.

Developmental perspectives on relationship and emotional development help create new ways to understand client experience for this group of people who have struggled to find ways to develop integrated relational and emotional selves. In this move from a medical model to one where emphasis shifts to emotional, relational and sensory development, I expect we will hear much more of the potential relevance of areas such as alexithymia, interoception and relational trauma in autism – a view shared by my colleague Professor Andrew McDonnell.

Developing relationships is therefore a critical part of any change process, and the practice of low arousal approaches requires a strong reflective process and framework to support caregivers so that they can examine their own contribution to challenging behaviours (McDonnell, 2010). With this in mind, I have developed a series of practitioner workshops, which have been piloted in Denmark, which aim to promote what could be called the “practitioner developmental agenda”. Such an approach acknowledges a shift away from medicalized ways of understanding client well-being, to approaches which help caregivers reflect on ways in which they can adjust their own ways of relating to support clients.

Reflecting on practice can be a difficult and indeed emotionally challenging task. Crucial to the Studio III approach is cultivating a practitioner mindset of curiosity about self experience, and how the people we support might experience us. In many ways this is a framework for “relational mindfulness” (Dan Hughes) in the sense of emphasizing awareness of the engagement between us and another people. Again, I stress that this is a model where the client is not the “patient”, but rather we are taking a hard look at ourselves in a non-defensive way.

Our relational workshops aim to develop understanding of how people with an autism diagnosis or developmental disability experience relationship with other people, and explore practical skills which might help caregivers working in this field develop shared trust and understanding in their interactions with the people they support. The key theme is one of facilitating discussion around placing relationship and engagement at the heart of low arousal practice. We explore the value of developing caregiver awareness of unhelpful relational and emotional dynamics in autism and intellectual disability settings. The success of developing caregiver interventions suggests that mindful awareness and response to relational dynamics is a key change variable in the well-being of people supported in care settings. Attunement to client relational experience is the essence of most contemporary therapies (eg. Beck, Rogers, Hayes etc.) and we explore practical ways in which caregivers too can create warm relational interactions which reduce client distress and challenging behaviour.

Some of the key themes we explore in our relational workshops are:

-Developmental perspectives on relationship and emotional growth; intersubjectivity, attachment styles and models of emotional development.
-The therapeutic value of promoting relational engagement and links between fulfilling relationship and client well-being.
-Styles of interaction which can be helpful in enabling this client group to successfully engage with caregivers and enable them to effectively communicate their needs and emotional     experience. In particular, we explore the utility of techniques such as motivational interviewing (Miller & Rollnick) and pre-therapy (Prouty) when working with clients who have a qualitatively different relational world, or who may have detached or withdrawn from day to day experience.
-A central role for how we can use mindfulness (Kabat-Zinn) as a relational tool integral to the professional developmental agenda of caregivers who are part of the lives of this client group.
-Using group formulation rather than functional diagnosis as a tool to understand barriers to relational engagement and idiosyncratic client preferences around social interaction.

Reprinted from Studio 3 UK

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