Category: Autism

A Neurodivergent Clinicians’ Personal and Professional Journey of Self-Discovery

Posted on by rezendevknowfully.com

My journey of self-discovery is probably similar to those of many others, with the exception that becoming a therapist, at least to me, is unlike any other career. The things I witness, hear, and experience, have no comparison. For the sake of myself and my clients I must continue to evolve, grow, and remain a lifelong learner. The space of shared stories and experiences is the one from which therapeutic connections can, and have, been made; where I join fully as a human being, and can bring together the various intersectional elements of my own identity. And just like my clients, I have my own story.

Recently, a student asked me about working with neurodivergent clients who have not experienced trauma. I thought it was a great question. In my experience as a neurodiverse therapist and citizen of the world, society is not set up for neurodivergent people and this binary of trauma or no trauma must yield to a more fluid, continuum-based way of thinking. Simply existing can feel traumatic for those who are neuroatypical.

In researching this topic through the scientific lens of my academic identity, I’ve simply not been able to keep pace. There is so much! Through another lens at the intersection of my identities, that of practicing clinician and neurodivergent, I have come to recognize the limitations of purely empirical investigation and have begun visiting social media sites in order to better understand the autistic and neurodivergent community through the lens of experience. I learned more from direct, and very personal narratives, than I did from any textbook or any clinical training.

Working with Bee: An Answer Deferred

Years ago, I worked with an older teenager, Bee, in a rural community who identified as queer. She initially came to see me because her gender fluidity and sexual orientation created conflict with her mother and her mother’s belief system. I want to emphasize the conflict was not between her and her mother, per se, but with the mother’s religious beliefs. This is not an uncommon experience where I practiced. While Bee had social anxiety and low self-esteem, she did have a good support system with her family and friends.

I worked individually with Bee and did some relational work with the family as well. Throughout our time together, she was able to build self-confidence and find employment. By her senior year, she was doing all kinds of things including taking on leadership roles as she fully embraced the trajectory into adulthood. It was for all intents and purposes, an effective therapeutic relationship in which we met the goals of treatment, individual symptomatology diminished, and her relationships improved, as did her attachment experiences and communication skills.

I remember one point during our time together when Bee asked me if she “could have ADHD or be autistic?” I said I wasn’t sure, so I did an ADHD screener, which was diagnostically inconclusive, after which we had several discussions about the results. I even talked about referring for a more comprehensive psychological evaluation, but did not really see the need for it. I talked about some traits but nothing within the clinical range. To support this, I pointed out to Bee that she was doing well socially, involved with extracurricular activities, had friends, and an active social life. At that point, we ended our work.

Through some happenstance around 2-3 years later, Bee’s family reconnected with me to share all the positive things that had occurred in their lives. I met this invitation with openness and curiosity. After the update of Bee going to college and studying a topic of her choice, I immediately shared my need to apologize. Bee asked what I meant. I remember asking, “do you remember when you asked me if you were neurodivergent and I said I really do not think so?” She quickly replied affirmatively.

I went on to tell Bee that I had spent the last several years learning about autism and ADHD, and that in retrospect, she was right. I admitted to her that I was neurodivergent, and that, “I believe you are too.” We shared a laugh about the experience. I was glad she was not angry and that she didn’t feel dismissed but said that “it would have been okay if you had been upset with me.” She knew back then that I genuinely did not think she was on the spectrum, but she was personally unsure. She knew I was not trying to dismiss her and reminded her of my recommendation for a comprehensive evaluation. But those evaluations were not as accessible or affordable as they later became. This was where the field was at that time, and it is where I was along my own path of self-discovery. Statements like the one I made back then, “You have some traits but don’t really meet criteria,” were likely very common before the idea of spectrum was more fully embraced. A few observable traits no longer mean that deeper pathology is being masked, awaiting a full assessment followed by a definitive diagnosis. Neurodivergence means just that…divergence, or variation on a theme. And that variation extends to race, gender, culture, and age.

I am glad I could repair, at least from my perspective, what I considered a therapeutic rupture, although Bee did not experience that rupture in a traditional way to the point that therapy hits an impasse or ends abruptly. The version of myself that spoke with Bee that day knew that she presented with all the “usual” observable symptoms that accompany autism, and that had I dug deeper, the diagnosis would have been clear. I missed or perhaps had resisted the diagnosis because I had not yet found a place for that label in my own identity. I could have let Bee’s narrative lead the way rather than the dictates of my formal training and that of impersonal scholarly investigations. Just as I now have a far clearer understanding of the complexity of my own intersectionality, I now more fully embrace the importance of honoring my clients’ narratives.

Postscript

Quite a while after my work with Bee and her family, I had taken my son at age 7 for an ASD evaluation. The psychiatric resident looked at him and said, “he is not autistic, you see this is the autistic bible––” he slapped his book on his desk––“I can tell by looking that he is not autistic.” My son returned to the room with blue cupcake icing on his face. I felt flooded with embarrassment and rage. I wanted someone to tell me why my son was struggling in so many ways in his life. I firmly said, “I want to see my attending physician.” She subsequently met me with compassion and kindness; however, not even an ADOS was performed.

The irony, or better yet, outrage I felt was because my son had classic symptoms of autism–– hand flapping, lining up toys, and a host of other stereotypical stuff for most of his early childhood, some of which reduced somewhat by age 7. Maybe the resident, and my attending, thought he was too old to be first considered for the diagnosis. But then again, I really don’t know the basis for their preemptory conclusion. I do know that the experience left me angry, feeling rejected, and dismissed, and like there was no help.

To have personally attended a state university that provided evaluations, only for the doctor to not even ask me any questions about my son was so disturbing, if not insulting. I am sure the progress note read something like, “Mother was emotionally unstable and reactive.”

I knew from that moment on I never wanted anyone else to feel that way. At the time of that visit with my son, I had been working on my PhD which paved the way for my own self-study and re-orientation to the whole experience of autism and neurodivergence. The research is clear, at least to me, as a citizen, parent, and clinician.

The field is failing neurodivergent people––kids, teens, adults, families, and couples. Social media has become a substitute, or perhaps a primary place for validation because they can’t receive it from the professional world. When clinicians and the medical community correct clients and dismiss the importance and validity of self-diagnosis, what can be expected? I view this very differently since social media was the source of my own self-discovery of neurodivergence, and a tool for assisting my clients on their own journeys. The entire experience, from my work with Bee to the evaluation of my son to my own self-acceptance, has awakened a deeper awareness that has highlighted the importance of embracing and advocating for the evolution of the professional landscape.

Jessica Kitchens on the Clinical Needs of Autistic Adults

Posted on by Psychotherapy.net Team
Lawrence Rubin: I’m here today with Jessica Kitchens, who describes herself as a conscious, inclusive, Indigenous and artistic leader dedicated to enhancing the lives of others through collaborative efforts. She also describes herself as Autistic, Indigenous, wife, mother of five, CEO, therapist, consultant, author, trainer, board certified cognitive specialist, addiction specialist and neuro diversity advocate. And of course, she is a clinician. Hi Jessica, thanks for joining me.
Jessica Kitchens: Glad to be here, Lawrence.

By Any Other Name-Late Identified Autism

LR: Let’s begin with terms. What is a late identified Autistic?
JK: Late identified Autistics are individuals that have been Autistic their whole lives but may not have been recognized as such because they have developed high masking capabilities. They decided that it was better for them to adapt certain behavioral patterns in order to fit in. It is something they have come to do automatically. They don’t know why; they just knew that they needed to. Later on in life, they recognized that this method of fitting into social norms, while self-protective, also came with a high cost. They begin to struggle as the demands of adulthood kick in, so to speak. Sometimes, they become aware of the burden of masking their own struggles when their child is diagnosed.
LR: late identified Autistics are individuals that have been Autistic their whole lives but may not have been recognized as such because they have developed high masking capabilitiesThe ability to recognize and then mask difficulties seems to be an advanced coping skill, but a very demanding, and perhaps tiring one. Do they reach a tipping or breaking point?
JK: Absolutely! There’s a lot of wear and tear that goes into high masking because of the psychological and emotional energy expenditure. Many of these individuals cope with masking by abusing substances or through process/behavioral addictions like gambling, shopping, and gaming, to name a few. That’s sometimes why they end up coming to see me, unless they are referred by family members or their employers or school personnel suggest it. But others simply burn out or shut down.
LR: I imagine they may also present with anxiety, depression, and/or substance abuse. But I can also see a therapist missing the Autism if they either don’t look for it or are not trained to look for or assess it.
JK: Absolutely. There are a lot of misdiagnosed individuals out there walking around with a higher proportion of them being female, but there are high masking males out there as well. These individuals may be diagnosed with bipolar disorder because the dysregulation can come out sometimes as mania, or they present symptoms of borderline personality disorder. I was personally misdiagnosed with generalized anxiety disorder.
LR: these individuals may be diagnosed with bipolar disorder because the dysregulation can come out sometimes as mania, or they present symptoms of borderline personality disorder
What are some of the reasons that a clinician, especially one that is non-Autistic, might miss the Autism diagnosis?
JK: Unfortunately, this is a common problem. We have a lot of professionals out there that are really good at what they do, but they have not had adequate or up-to-date training on what Autism now looks like, because they’re still looking at very old stereotypes. It wasn’t even in the DSM until 1980, and even then, they still had a very distorted view of what it was.It’s only now that Autistic researchers are coming out and talking about their own lived experience and we’re finally changing what the diagnosis looks like because there’s a lot of what I would call iceberg Autistics out there. They’ve masked for so long and kept a lot of this stuff underneath. Therefore, a lot of clinicians are over-relying on stereotypes and media representations of lower functioning, higher support needed individuals like Rain Man. They miss the diagnosis of Autism when they see someone like me, thinking something like, “you don’t you don’t look like my cousin who has Autism. So unfortunately, there are a lot of clinicians out there that are doing some harm because they do not have up-to-date training.
LR: there are a lot of clinicians out there that are doing some harm because they do not have up-to-date trainingSo up to date training would tell clinicians that Autism is far more, or far different than being able to count 496 matches on the floor, stimming, self-harming, or having real difficulties making eye contact, to name some of the more familiar symptom clusters. What are the new generation of trained clinicians looking for?
JK: A lot of times, these clients come in because of dysregulation, even though they may not use the term. They may find themselves easily dysregulated in their work environment or in their home environment. They may actually have a visceral, nervous system response to sounds and lights. And since Autism is a dynamic disability, they may struggle in their relationships because of difficulties with pragmatic communication. On a given day, these folks, me included, may have difficulty finding the simplest of words to use. When a clinician is trained to look for these subtleties, they are in a better position to ask the right questions.
LR: Are there benefits of first being diagnosed in adulthood?
JK: That’s a good question and one that a lot of them must decide for themselves. A formal diagnosis in certain settings, like school or work, can help them get accommodations, such as adaptations to the sensory environments, that can put them on par to where they can now be equal and function at a baseline level with some of their neurotypical peers. Sometimes they can get them without a formal diagnosis, but some work environments are exceedingly difficult in allowing that. And sadly, we still have a lot of ableism in work environments.For others not necessarily pursuing accommodations, formal diagnosis can empower them to re-consider their dysregulation, learn coping mechanisms such as mindfulness, and review their life in a way that now makes sense to them.
LR: sadly, we still have a lot of ableism in work environmentsWouldn’t we the want the newly diagnosed adult to be referred to a clinician who knows how to help this particular client?
JK: Absolutely, but unfortunately, there are clinicians out there that can do more harm than good if they don’t have the right knowledge to work with these clients. I’m very picky about who I work with because there’s a lot of nuances that go with the neurodiversity affirming framework, such as learning about the nervous system functioning of an Autistic adult.
LR: Have you seen any downsides to a person being diagnosed in adulthood with Autism?
JK: Within work environments, there are instances of ableism among managers or supervisors who work against accommodations. The problem can be institutional.
LR: So just as there are institutional racism and institutional homophobia, there is also institutional ableism?
JK: It’s heavy and it’s ingrained in all aspects of our culture. One of the things that I’m working on in my PhD research is decolonizing ableism by utilizing and looking at indigenous perspectives of Autism through my own and other tribes. I’m trying to view it through an indigenous and a decolonizing framework, because the Western medicine is entrenched with a lot of deficit-oriented stereotypes. It’s everywhere. It’s in our schools, it’s in our work, it’s in medical institutions. We do have capabilities. We want people to recognize that we are autonomous persons, and just because we struggle with certain skills, there are many things that we are still capable of, and many Autistic adults are quite gifted in many ways.
LR: How has being a late diagnosed Autistic influenced your professional trajectory and shaped who you are in the therapy room with clients?
JK: It’s changed everything. I was formally diagnosed a few years ago, but it was my youngest daughter of my five that was diagnosed before any of us, and now my youngest three are all formally diagnosed with ADHD and Autism. It’s one of those things that’s literally changed every facet of my life. Every conversation that I have with people is entrenched in this.The ways I review my childhood and how I view my future are now entrenched with this view which has also affected my research and PhD journey. I don’t ever see it going back. I’ve had to grieve a lot of my life, but there is no me without Autism because this is who I am. It explains so much. It explains all the things that I’ve probably struggled with my whole life.

Neurodiversity Affirming Intervention

LR: In the case of an Autistic adult, what is neurodiversity affirming intervention?
JK: A person-centered orientation seems to be the best for most of these clients. But knowledge and the understanding of certain Autism experiences like pathological demand avoidance or rejection sensitive dysphoria, goes a long way. So does using correct terms such as identity first language—using the word ‘Autistic,’ rather than ‘a person with Autism.’
LR:a person-centered orientation seems to be the best for most of these clientsWhat do you mean by saying that a person-centered approach is best?
JK: Meeting them where they’re at – a lot of times clinicians have this view that they need to fix people. That’s not what it is. You know? It’s more about matching that congruence and recognizing that you we are capable of so much beyond the narrow limits of what the diagnosis suggests. It’s about recognizing what skills can actually help us be the best that we can be as a person, whatever that looks like. Whether it’s mindfulness, EMDR, or CBT. It’s about grabbing from modalities of all types. Everybody’s different.It’s not about coming from a place of judgment. I don’t want to push my views on my client of what I think they need to be working on. I want them to have an idea of areas they want to grow in and using whatever tools and skills I have to help them get there.
LR: there is this misconception that people are being overly diagnosed, that we’re handing it out like candyAre there myths and misconceptions that clinicians bring into this work that hinders intervention?
JK: There is this misconception that people are being overly diagnosed, that we’re handing it out like candy. Clinicians who believe this go in with automatic blinders. In reality, Autism goes back generations in families, so a new diagnosis should not be that surprising or unlikely. And because these adults are bringing their children in for diagnosis, it makes sense to either formally or informally assess and perhaps even help that parent. And while it’s not a myth or misconception per se, internalized ableism on the part of the client or clinician, or both, can hinder the intervention process.
LR: Have you encountered resistance from some clients who are on the doorstep of the diagnosis?
JK: The only resistance that I’ve noted has not come from the clients themselves. It has been from their families because a lot of them take it as an affront to who they are or believe in some way that they caused it. And so again, that goes back to some internalized ableism. Sometimes, these clients come to me already knowing about the possibility. A lot of them actually did. Sometimes, it comes to them after I’ve planted seeds.
LR: the undiagnosed or unaware Autistic clinician is going to miss it in their clients if they’ve missed it in themselvesIs an undiagnosed Autistic therapist a potential risk to either neurotypical or neurodiverse clients? Or is the therapy potentially limited by a clinician who is unaware of – or resistant to – acknowledging their Autism?
JK: The undiagnosed or unaware Autistic clinician is going to miss it in their clients if they’ve missed it in themselves. I’ve been there too. I have to look back and reckon with the fact that there are some clients with whom I’ve missed important aspects of their experience because I wasn’t thinking about the possibility of Autism.

Transitions and Unique Challenges for the Autistic Adult

LR: We know that stress increases as life demands accelerate, so are older teens and young who have not yet been diagnosed at a greater risk?
JK:  It’s interesting that you ask that question because I was a co-researcher on a Delphi study on what independent living looks like to Autistic adults. And as far as moving out on their own or going to college or working, many of these young people start struggling all of a sudden, or at least far more than they had previously.They did well at home and well in school because there was a lot of structure and stability. But now all of the sudden they’re required to function on a higher level. Logistics are a different monster altogether such as paying bills and adapting to new, and complex sensory and demand environments.
LR: Is the diagnostic threshold different for teens than it is for adults?
JK: I would expect the clinician to be able to identify high masking, and to use multiple sources in the assessment of younger clients who may not be able to report fully. I think it’s often harder to diagnose a child because they can’t speak for themselves. If the clinician uses appropriate measures and asks the right questions, it can actually be easier because they can ask about the internal processes, not just your behaviors and what you do and what others see, but what the internal processes are.
LR: Can you think of a few assessment instruments off the top of your head?
JK: The Social Responsiveness Scale is one that was done on me. I felt like, man, that asked a lot of the right questions, and there was also a Sensory Profile that really nailed it, at least for me.
LR: many people on the spectrum actually have higher than average affective empathyWhat are some of the relationship and family issues that Autistic adult clients bring to you?
JK: There is an interesting challenge for Autistic adults called the double empathy problem. One of the stereotypes is that these people lack empathy, which is the furthest thing from the truth. Many people on the spectrum actually have higher than average affective empathy. The disconnect comes from alexithymia, meaning they may not be able to label that feeling, but they can feel it. A lot of them do struggle with Theory of Mind (ToM), also known as cognitive empathy. That’s the problem with necessarily putting yourself in the shoes of the individual and understanding their perspective.So, you might have two individuals with high affective empathy, but differences in their cognitive empathy. The double empathy problem manifests in, one or the other member of the couple or family member, not feeling understood. They might butt heads, which then leads to a lack of reciprocity. That’s one of those nuances that a non-neurodiversity affirming therapist might miss.
LR: What might be some of the challenges to Autistic parents?
JK: Parents also struggle with the double empathy problem. Some of the biggest communication struggles I had with my teen children were whenever we were coming from different places of reciprocity or understanding each other’s perspectives.
LR: What is internalized ableism?
JK: As a parent, it could be expecting an Autistic child to do something a non-Autistic child can do or expecting a partner to somehow be or act normally, without respecting their diversity and difficulties. That child or adult then internalizes that prejudice and may struggle unnecessarily, beating themselves up, instead of accepting certain limitations and learning effective coping skills.
LR: You identify as indigenous, and work with indigenous clients? Does Autism manifest differently among indigenous people?
JK: Absolutely. Here in Arkansas, I don’t have as many clients as I would if I was back in Oklahoma 20 years ago, which is where my tribe is, the Potawatomi. And we know the Māori in New Zealand have a word for Autism called Takiwãtanga, which means in your own time and place. They have a more positive frame of mind for Autistics.
LR: many Autistics have high affective empathy, and deep sense of justiceWe tend to pathologize differences, but I am now wondering about some of the unique skills and advantages associated with Autism, perhaps that a clinician could capitalize on.
JK: I feel like it’s different for everybody, but many Autistics have high affective empathy, and deep sense of justice. A lot of us are really hard-core advocates in general because of our empathy. It tears us up whenever somebody is being mistreated. Other than that, the noting of patterns. For me, it’s behavioral patterns. I was able to learn behavioral patterns early on to mask my differences, but it can also help me to note incongruences with my clients. We can also be quite analytic. Clearly, we have many broad capabilities, so stereotypes often simply fall short.
LR: Finally, what are some resources and organizations that clinicians can use to improve their identification and intervention skills?
JK: If you’re going to work with Autistics, you need to know about pathological demand avoidance, also known as persistent drive for autonomy, which is PPDA. PPDA North America is a useful resource for this, but there’s also NeuroClastic, which I believe is a 501 C3. They work the business side; working with businesses and hiring Autistic individuals and they do a lot of good. There’s also the Autistic Self-Advocacy Network.
LR: Is there anything I failed to mention, Jessica, or questions I could have asked?
JK: There are so many nuances to appreciate about this population, and it is so much more than reading the DSM when you work with these clients. You’re going to learn the most from individuals with lived experience and those who have entrenched themselves into Autistic research.
LR: On that note, Jessica, thank you so very much for your expertise and sharing your valuable time.
JK: No problem. I really appreciate it.

Looking Beyond Trauma: A Neurodivergent Therapist Shifts Her Clinical Focus

Posted on by Psychotherapy.net Team

As a therapist, I often find myself navigating the complex layers of my clients’ lives, working to untangle the web of trauma and its aftermath. In my years of practice, I have had the privilege of helping many individuals heal from deep traumatic wounds. I never planned on this, but my first job laid it in my lap, and I’ve loved every minute of it since. The hardships that I’ve seen people go through and be able to heal themselves are nothing short of impeccable. It’s almost indescribable. However, one particular case has profoundly impacted my perspective and approach: the story of an 18-year-old biracial male recently diagnosed with Autism, whom I initially treated for PTSD and trauma-related attachment symptoms. I referred him for an ADOS evaluation and looked at the report. I was glad that this assessment lent clarity but frustrated at myself that I didn’t see it sooner.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Missing the Autism Tree for the Forest of Trauma

Alex came to me with a history marked by significant trauma; he witnessed domestic violence most of his childhood, was abused by a daycare worker, and did not have any relationship with his biological father. His experiences had left him struggling with severe PTSD, anger outbursts, and disengagement from school. He had relational problems with his mother and would not often communicate.

My initial sessions were focused on addressing these urgent, debilitating symptoms — the depression and the outbursts. My training and instincts as a trauma-focused therapist kicked in, and I dedicated myself to creating a safe space for him to process and heal. We did a lot of experiential work, along with play and gaming therapy. We worked on externalizing all that had been internalized — bringing it out and releasing the frustration of not having a relationship with his father, anger towards his mother, anger towards the men who abused her, and fear. We also spent some time deepening the relationships between the sibling and mother.

However, as weeks turned into months, something nagged at the back of my mind. There were aspects of Alex’s behavior that didn’t entirely fit within the framework of PTSD. After moving through the trauma work and no longer meeting criteria for PTSD, he still did not engage in effective two-way communication with me — his answers were often short, and he remained hyper focused on his hobbies.

My focus on his trauma had been so all-encompassing because of my own hyper focusing, that I missed the autism, which in retrospect, had been masked beneath the trauma only to surface afterwards. I saw this a lot in my practice and experienced it myself. And it’s not as if I could have “treated” the autism, but perhaps I could have been more helpful had I helped Alex to better understand himself, and not pathologize himself.

It wasn't until I embarked on my own journey of self-discovery, guided by insights from other autistic providers, that the pieces began to fall into place. I realized that my training and the field’s emphasis on trauma had not adequately prepared me to see neurodivergence, especially in individuals whose trauma symptoms were so pronounced. This is a common question I get from students, “why are we not prepared for neurodivergence?” I have a few theories, but this is just where we are. We need to listen to the autistic and other neurodivergent communities, their narratives, their stories, because our research and clinical training can’t keep up. This realization was both humbling and enlightening.

My work with Alex prompted me to seek further education and collaboration with autistic and neurodivergent colleagues. Their perspectives and experiences have been invaluable in reshaping my approach to therapy. I now understand that trauma can sometimes overshadow neurodivergent traits, making them harder to recognize. This has reinforced the importance of a nuanced, multifaceted approach to therapy. I have read that some do not agree with this concept, but I have seen this over and over in my practice. I’ve also witnessed narratives of where once their ADHD is managed the autism pops its head out, surprise!

In sharing Alex’s story and my journey, I hope to encourage other therapists to broaden their perspectives, as I have mine. I have come to value the necessity of being vigilant and open to the possibility that neurodivergence might be present even in the most trauma-affected clients. By doing so, I believe that I have been able to provide more comprehensive and compassionate care. I have also come to value the importance of ongoing learning and self-reflection — not just for me but for the entire field. Alex’s story is a testament to the importance of this mindset. As a neurodivergent therapist, I hope to continue in my commitment to being informed and adaptive, ensuring that I do not miss the vital aspects of my clients’ identities and experiences. Through this commitment, I can better help my clients to heal and thrive.

Postscript

Once Alex received the autism diagnosis, the mother and I met to review what this all means for her and her almost adult child. We’ve spent a lot of time talking about transitioning into adulthood and the challenges and strengths that Alex has. This diagnosis hopefully opened the door for more supportive services, and it opened up the pathway for the mother to start examining herself in a new light. As she and I talked, she started to look at herself through a neurodivergent lens and her experiences made more sense to her. We also talked about how not knowing has impacted her and Alex’s relationship negatively in the past but now they have a new perspective on things they can connect in a different manner. They have internalized ableism within her parental expectations, which often led to highly intense conflict. But now, they see themselves as a nervous system responding within the context of each other rather than blaming one another. This opened up space for compassion, understanding, and empathy.   

Questions for Reflection and Discussion

How might you have worked with this client?

What are some of the gifts a neurodivergent therapist might bring to therapy?

In what ways might a neurodivergent therapist struggle with particular clients?  

Stealing a Passage Home: Narrative Therapy to Re-claim Honesty

Posted on by Psychotherapy.net Team

First Meeting: Dignity and Grace

What I most remember about my first meeting with 12-year-old Dilip were his deep brown eyes which spoke to me of a tenderness and sadness that I am not used to witnessing in boys of his age. He was accompanied by his mother, Sangita, who entered my room with the grace and dignity that came to characterize her in every one of our meetings. I didn’t know then how much suffering that dignity and grace had survived.

Sangita had explained to me on the phone that she was desperately worried about her son who had been stealing for some years from family members and shopkeepers. More recently the stealing and lying had spread to friends’ houses and to school, sites that had previously been exempt. Dilip’s intelligence was clear in everything he did. He had recently helped draw up plans for his mother’s projects on her architectural design course, including 3D movies and elevations. Sangita proudly told me how he had set up his own business repairing electrical items he had found on the roadside in “inorganic rubbish collections” and then successfully selling them online to help raise money for his family when times had been hard.

She told me how she and her husband, Kulwinder, would lie awake at night contemplating how Dilip’s entrepreneurial abilities might take him in the “wrong” direction in life and how his prodigious intelligence might be put to ill use. Sangita confided in me that they were worried that one day they might “see him behind bars.” I marvelled as I looked into this young man’s eyes. He seemed like a vulnerable innocent — not an enterprising entrepreneur with a dubious life ahead of him.

Sangita’s voice quietened, and her face became strained as she began to relate to me how Dilip’s brother, Harman, had been diagnosed with leukaemia five years previously and was now in remission. She spoke carefully and softly with the matter-of-fact-ness of someone for whom devastating events have become routine. She told me how they had only been told of the diagnosis shortly after they had left India and arrived to start a new life in New Zealand.

Kulwinder and Sangita had taken Harman with them, ahead of the other children who were to remain in India until their parents had found a home and work and had applied to become New Zealand residents. Dilip was to remain with Sangita’s in-laws and, because they had room for only one child, Dilip’s younger sister Ravi went to live with family friends nearby. Kulwinder and Sangita had adopted Ravi after the Indian earthquake of 2001 when she was four months old. She required special and tender care as she had not only been orphaned by the earthquake but also suffered from Autism and Dyspraxia.

Sangita leaned forward as if her shoulders were struggling to hold the weight of her story. She told me how she had returned to India to visit Dilip and Ravi. No sooner had her feet touched Indian soil when Kulwinder phoned her from New Zealand and broke the desperate news that Harman had a severe form of Leukaemia which had already spread to 98% of his body. He had immediately been admitted to hospital where he had begun radical treatment.

She told me how the doctors broke the news that he would be starting intensive chemotherapy and would “need his mother.” Faced with the knowledge that Harman was unable to receive the treatment that he desperately required in India, Sangita and Kulwinder made the difficult choice that they should remain in New Zealand with him. Torn between her children, Sangita was given a visa to return whilst their residency application, already delayed for a year, was being processed. She returned to New Zealand, little knowing that it would be more than two painful years before the family would be reunited.

As they had yet to become New Zealand residents, they were not covered by New Zealand medical care and had to meet the expenses themselves. To do this, they had to draw upon their savings and that of many of their family back home, running up bills of half a million dollars for their son’s radical treatment.

Somewhat shaken by Sangita’s story, I silently held her eyes to acknowledge the pain which she had conveyed with such dignity. Together, we then turned to look at Dilip. Dilip’s eyes had remained downcast throughout his mother’s tale. Collecting myself, I realised that I must turn my attention to him and the impact of his mother’s account. In his eyes, if not in my own, the stealing problem would have centre stage. Only too aware of Dilip’s nervousness and the likely embarrassment that a stealing problem might have brought upon him, I was quick to externalise the apparent problem and to add lightness to the tone of my voice. I said, “Dilip, your mum tells me that she has been worried because she thinks that there is a stealing problem that has been trying to take over your life and that is why she has asked us to meet. Is that what you thought too?”

Dilip uttered a barely audible “yes.”

I gently enquired when the stealing problem had first come along and how it had made its presence felt in his life. He informed me that it had begun when he was five, during the time he had been left behind with family in India, anticipating his reunion with his family in New Zealand.

Speaking through her tears, Sangita, told me, “He was not sure we would call him back. He was so angry that twice we had to cancel his return because of Harman’s illness and problems with the visa. He told us that he would only believe that he was coming to us when he was sitting on the plane. Many times, Kulwinder called him because our relatives said that he was bullying other kids. Even the bus driver was not willing to take him on his school bus. When Kulwinder called him, Dilip was not saying anything. He was just silent. His father was angry that every day we were counting each dollar because Harman’s treatment was so expensive, and Dilip didn’t speak when we called. Kulwinder said that it was not worth phoning him anymore. We had been telling Dilip that he would be coming soon, but in the last few months, he lost patience and said ‘every time I pack my bags nothing happens. I will only believe I am coming to New Zealand when I am on the plane.’ Our family in India had a servant who had known Dilip from birth. One day he called me and ordered me to ‘come here and take this child or pack up and come back to India.’ It was a very bad time for all of us.”

“Did he have some idea of what was going on in Dilip’s heart?” I asked.

“Yes,” she replied.

“Would he have said that his heart was breaking?” Sangita nodded, tears on her cheeks. “Dilip, was your five-, six- or seven-year-old heart breaking?” I asked.

“Yes,” he replied. “Was it heart-breaking for your mum and dad that your heart was breaking?” Sangita began to sob. “Have you talked about these matters like this before?” I enquired.

“Never,” she choked out through her tears.

“Had your family’s heart been breaking in that time? Not just your heart and Dilip’s heart but your husband’s heart and perhaps your daughter’s heart?”

“Yes,” Sangita replied.

I noticed that Dilip was sitting uncomfortably on the edge of his seat. I thought to ask him whether he would prefer it if we were to speak alone. Before I did so, Sangita swiftly looked at her son and said, “He wants me to sit outside.” Dilip nodded and she discreetly left the room.

To lighten the sadness that had fallen upon the room, I wondered aloud, “Is this stealing problem an international stealing problem that has followed you across continents?” The corners of Dilip’s mouth rose slightly.

“Did you know,” I enquired, “that, in all the time that I have talked with young people about the problems that have bothered them, I have discovered that sometimes problems start out trying to be helpful and only later become troublesome? Might that possibly be true of the stealing? Did the stealing try to help in any way with the sadness of being left behind in India and the sadness for your brother in his illness?”

Dilip replied, “Yes, maybe it took the sadness away a bit. It did help to start with!” Dilip’s body seemed to relax, and his eyes focussed intently upon me. Alarm crossed his face and tears filled his eyes as he said, “I wasn’t sure they would call me back.”

I said, “Call you back? Do you mean that you didn’t know whether or not you would ever be called back to live with your family again in New Zealand?” Dilip nodded. “Dilip, does anybody know just how sad you have been?” Dilip shook his head slowly and thoughtfully.

“No one knows. I don’t want my mum and my family to be sad.”

Realising that this sadness was at the heart of the problem but also knowing that I must tread carefully, I gently asked, “Dilip, would you mind if I try to understand a little more about this sadness?” He hesitated but then nodded his approval. “Could I start by asking you how big the sadness has been?” He looked a little confused. “If we could measure the sadness [a concept of David Epston’s creation], and let’s say the most sadness there could ever be is the width of this room which is, oh, about three metres, how much sadness was there in India when you feared they wouldn’t call you to live with them in New Zealand?”

“Two and a half metres,” Dilip replied with considerable certainty.

“And how much sadness is there now here in New Zealand?” It turned out that now there was between one and one and a half metres of sadness remaining. When I enquired, Dilip told me that the remaining sadness came from missing the family he had left behind in India.

“They keep coming to visit but they can’t stay because of their visas. I don’t want them to be sad either.”

I asked, “Are you worried that they will be sad if they know of your sadness in the same way that you are worried that your mother and your family might be saddened by your sadness?” Dilip held my gaze intently as he nodded in agreement. I gently asked if he thought that talking about their shared sadness would bring about more sadness for everyone.

Timidly he said, “Talking will make them more sad. I don’t want them to know.”

Sensing that our conversation might be on the verge of being overwhelming for him, I asked him if he thought it was time to welcome his mother back into the room. He nodded, adding, “But I don’t want to talk about what happened.”

Aware that the sadness was key if Dilip and his family were to be rescued from the effects of his stealing reputation, but also mindful of the need to honour Dilip’s tenderness, I asked him if I could briefly mention that we had talked about his life in India and how the stealing had come about. He nodded.

“Could I also mention the sadness and how it had become less since he had been reunited with his family?”

Dilip nodded hesitantly but went himself to invite his mother to return.

Sangita came into the room hesitantly. I pondered how much hope she had pinned on the time I had spent alone with Dilip.

“Sangita, Dilip and I have been talking about his time away from you all in India and how the stealing began. He felt very sad whilst he was without you but, since returning to be with you, the sadness is very much less.”

I saw Sangita’s tears begin. Mother and son glanced at each other. The sadness was palpable.

“Sangita,” I ventured, “have you talked together as a family about all that has happened to Harman and to each of you?” Dilip’s eyes widened in what suggested to me renewed alarm. “No, not even Kulwinder and I have talked.”

I asked, “Has the strength that this ordeal required of you left little room or time for really feeling or really talking?”

“Yes,” she replied. “Every year something big is happening. When I was saying goodbye to my brother-in-law at the airport last week, he said, ‘In your life it is always headlines, not small news.’ There are always big things happening. When Harman got sick there was no one. We were here alone. There has been no time to talk.”

I realised that for the previous few years, the family had been just surviving all that had happened and had not had the opportunity to reflect. I was also aware of the need to honour the tenderness of this family who had lived through so much with grace and dignity. Contemplating the way forwards, I felt unable to venture further into the territory of their sadness. To do so would have been to trespass unnecessarily into their pain when surely there were other routes available. With this in mind, I asked, “If we were to find a way to try to put the sadness to rest without talking about it directly, would that seem helpful?” Sangita and Dilip, without reference to each other, nodded in unison.

“How are you hoping that our conversations together might help Dilip and your family?” I enquired.

Sangita gazed at me for a moment and then said, as if uttering a prayer, “we want to know him better again. I would like to try to help the sadness not to come into his life again. I would like him to be happy.”

Second Meeting: Honesty as a Way through Sadness

A week later, Kulwinder was the first to put his head around my door. I had hoped that he might join us. Dilip and Sangita followed. With Dilip’s and Sangita’s permission, I summarized for Kulwinder our conversation of the week before. Kulwinder quietly took in my words. I proposed that whilst talking might be one way, there are other ways to tend to wounds. Turning to Dilip, I asked, “Am I right in thinking that your family’s suffering make you suffer?” He nodded without hesitation. “May I speak a little about your suffering as I understand it?” The family nodded their consent.

“This family has endured much. Many people have told me that when there is too much suffering, they come to believe it is better not to talk about it. Instead, they decide to get on as best they can with their lives. And they say that has worked for them for a while. But then they tell me that the suffering and sadness catch up with them; it can reach them in the strangest ways. I am not sure about this, but could the stealing have been a way to draw others to the suffering that you have all gone through? It is a measure of this family’s wonderful dignity, endurance, and perseverance that you have not cracked under the pressure of so much suffering and sadness.

“Dilip, you are a very young man and I think you can help your family out of their sadness. I know it is odd to turn for help to one of the very youngest as usually we turn to the eldest. But you are different. You have talents which show that you are a very quick learner. What you can do — and we all will help you with it — is to prove once and for all, beyond a shadow of doubt, that you are an honest boy, son, and man to be. When you do, I will ask your family to show you their happiness and, when you think people are happy enough, then, and only then, we will talk about the sadness from the past. Then we will see how everyone can be together in sickness and in health as a wonderful family who suffers and has suffered. And, Dilip, you will always know when you grow up that it was you who led the way from sadness to happiness for a family who has had more sorrow than almost any other I have known. But yours is also one of the strongest families I have met, and I am proud to know you all.”

Turning to Dilip, I addressed him alone.

“Dilip, I am going to suggest a way of restoring your reputation as an honest person. You won’t need to talk about your feelings right now. Would you be interested in such a way, even if I were to tell you that for it to work I cannot reveal to you exactly what it involves, and you will only discover this over time?”

Surprised, Dilip looked towards me, a shy enthusiasm for the project I had outlined beginning to light up his face. He nodded and then looked to his parents who nodded their assent. I said, “This is an idea that has worked many, many times before. Do you trust me that I have a way to prove beyond a shadow of a doubt that you are either a stealer or an honest boy?” Dilip’s eyes grew wider, this time with intrigue. He mouthed a silent “Yes.” I added, “I cannot give you all the details now, but next week I can meet with you all and we can begin. Today, could you help me understand more about the stealing and the reputation it has left you with?” Dilip, Sangita, and Kulwinder nodded in agreement.

I said, “Now, to begin, I need to know who in your life cares whether you are an honest boy or a stealer [Family members and friends are recruited as members of the young person’s community for the restoration of honesty].”

Dilip looked for assistance from his mother, who replied, “Well, his grandmother. She cares for him very much.” Then directing herself to Dilip added, “And your uncle, my sister, your brother, and your teacher. She is very much worried about you.”

I asked, “Is there anyone else in India who particularly cares about Dilip’s reputation as a stealer?”

“His grandparents and my father in particular” ventured Kulwinder. “Not everyone in our family knows but my parents are worried about his future and about what will happen if the stealing and lying grow with him.”

“And Arthur and Julie and Daniel,” added Sangita.

“Who are Arthur and Julie and Daniel?” I enquired.

“Arthur,” Sangita replied, “is an elderly man who is a friend of the family. He is very fond of Dilip and Dilip is very fond of him. Arthur lets Dilip spend time with him in his workshop, he shows him how to use tools and make all sorts of things. Daniel is Dilip’s school friend and Julie is his mother. Julie was the first person who talked to us about the stealing in New Zealand. She carries a loving heart. She didn’t want to punish him. She just talked kindly to Dilip. After that I told Dilip not to go to anyone’s house anymore.”

I ask, “Dilip, how has the stealing affected these people who care about you? [The effects of relationships of the stealing reputation are established] Let’s take your grandfather for example.” Dilip remained silent until Kulwinder rushed to his rescue.

“His Granddad — Sangita’s father — is worried about what will happen to his life. My parents love him very much and you know what it is like when a loved one is not on the right path. It is very hurtful. It breaks your heart.”

I ask, “And Dilip, what do you think the effects will be upon these people who care about you when they find out that, beyond a shadow of a doubt, you are now an honest boy and honest son? Can we start with your Granddad?”

Dilip looked surprised by my question but seemed to be sticking with it. I offered a question to scaffold his response.

“When he finds out, will he call on the phone or send you an email? What will he say?”

“He will be happy,” Dilip said shyly. I asked him a question closer to home.

“Do you have any idea what a reputation for honesty would mean to your parents?”

Dilip replied, “It would bring peace and happiness to their hearts.” Sangita, tears in her eyes, looked to her son and replied to my question.

“We love him very much. Knowing that Dilip is an honest boy would be the biggest gift to us. The stealing has weighed on our hearts. We have come to feel that we cannot believe in what he says. It will take time for us to know if he becomes honest again. We have to be sure his honesty is real.”

Third Meeting: The Idea is Revealed

“Dilip, as I said, this is a tried and tested way for you to prove that you have regained your honesty. Are you sure you want to go ahead?” Dilip nodded hard. “Okay, I am going to propose that you are honesty tested.” The family looked at me quizzically. “Dilip, as these are tests, I cannot tell you the details because if I did it would mean you were not being tested. The honesty tests will take place over a period of time. Your parents will decide how long the tests will take — it could be weeks or months — to satisfy them that you are honest. When the time comes, when you have proven beyond a shadow of a doubt that you have redeemed your reputation as an honest young man, we will hold an honesty party to celebrate. Now, if you are sure you wish to go ahead with the honesty testing, let us shake hands to confirm our trust in one another.”

Dilip dutifully placed his hand in mine and the deal was sealed with a firm handshake [Consent is given for honesty testing to restore an honest reputation].

“Dilip, now I am going to meet privately with your parents to let them know what this challenge to restore your honesty involves. Then you and I have a letter to write.”

After Dilip had left the room, I outlined for his parents how we might set the honesty tests [Setting up the process of honesty testing].

“Over the next few weeks or months, you will set Dilip tests which will confirm him as either an honest boy or a stealer. These must be carefully planned so that he has no idea they are tests. Just to give you some idea of what other families have done in the past, I can tell you that some parents have left change where it is visible when they have left their child briefly alone in the car. Others have left money on the hall table, etc. The tests should vary in location and be as unpredictable as possible. It would be a good idea to involve Dilip’s supporters. For example, you may want to ask Arthur or Julie to set some of the tests in their homes. It is up to you to decide how long you continue to set more honesty tests. It is all a matter of how much time and how many successful tests you think you need to be convinced that your son is truly honest. After that you might like to consider a further period of probation without tests until you are both sure that he has restored his honesty.”

Kulwinder and Sangita decided on a period of three to four months during which Dilip would have to face the challenge of six tests followed by a probation period of three to four weeks. After they had asked a few questions, I explained that it is vital to the success of the tests that others who care for their son are enrolled as witnesses. To that end, I would assist Dilip to write a letter in which he would formally disavow his stealing habit and declare in writing how he wished to renew his honesty. Dilip would be expected to post or email this letter to the concerned parties or read it to them over the phone. Immediately after each test had been completed Dilip would be required to call or contact each person on his “honesty team” to declare the result revealed to him by his parents.

Dilip returned, and we slowly and carefully crafted the following letter to send to his honesty supporters. In collaboration, we composed the letter by way of an extended enquiry which was continually interrupted so I could write down his answers [Co-crafting of letters].

Dear Granddad, Grandma, Uncle Sanu, Uncle Achyuta, Auntie Amrita, Auntie Pavani, Arthur, Julie, Daniel,

I would like to ask you for your help in changing my reputation. As you may well know, I have developed a reputation as a stealer. This reputation has grown over the last five years or so even although it has come and gone several times.

This stealing reputation has caused me and the people who care about me a lot of worry. It has been hard for me to change this reputation on my own because a reputation like this is very powerful. It is so powerful that it has followed me all the way from India to New Zealand.

I know that the people who care about me are worried about my future because they fear that this reputation could grow even bigger.

The stealing reputation has meant that lately I haven’t been able to stay at friends’ houses. This makes me sad.

I want to be able to prove to you all that I am now on the right path. I want to bring peace and happiness to your hearts and to reassure you that I will have an honest future.

I don’t expect you to believe me if I say there will be no more stealing. Kay, a counsellor, has told me that it is possible for me to prove that I can be. To prove to you that I am honest I am willing to go through some honesty tests that my parents will set for me with Kay’s help. I and my parents will call you after each honesty test to tell you the result. When I have passed all my tests and enough ‘honesty time’ has passed to prove to you that I now deserve a reputation as an honest boy, I will invite you to my ‘honesty party’. If you cannot come, then I will invite you to write me a letter or send me an email that can be read aloud at the party.

Love,

Dilip

I read the letter to Dilip, waiting for him to signal his approval after each paragraph. He looked at me thoughtfully before commenting, “I think they will trust me to get the better of the stealing.” Together we agreed that all the letters would all be delivered the following week. A last-minute amnesty was offered to Dilip so that he could admit to any stealing that might have been worrying him because it was undiscovered or not proven [The opportunity for eleventh-hour admissions].

Fourth Meeting: Eleventh Hour Confessions

We met again in a week. Kulwinder was eager to tell me of a very recent development: between meetings, perhaps because of the amnesty, Dilip had confessed to having stolen and eaten a box of chocolates bought as a present for a family friend. Although upset that the chocolates had been stolen, they were relieved that he had confessed, especially as this was his inaugural confession. He had never admitted to a theft before despite at times very lengthy interrogations to establish his wrongdoing.

Both parents had taken heart at his confession, as did I. This event seemed like a timely departure from the path that Dilip had been travelling. I hoped that it would spur their confidence in Dilip’s commitment to honesty and decided to make the most of it.

“Does this confession speak of anything that you are proud of in your son?” I enquired. Sangita eagerly responded.

“It shows he wants to be truthful; it shows the purity of his heart.”

I asked, “Have there been any other ways that Dilip has shown you the purity of his heart lately?” Kulwinder spoke of how Dilip had been listening to his mother more and contributing to the care of his sister.

“I believe he has more strengths than he can see!”

“And how did you get on with the letters, Sangita?” I asked.

“There was only one problem. He didn’t want to give the letter to Arthur. He actually cried the night before Arthur was due to come with a pet rabbit for him. I said, ‘You have to tell him, or you won’t be going to his house.’ The next morning, he said that he would give him the letter. He gave it as Arthur was leaving; it was hard for him, but he did it.”

I asked, “And how did the other people whose support Dilip called upon respond?”

Sangita was quick to reply that, when Dilip had bravely read his letter to them on the phone, her father and mother had said they would be very happy if the stealing went away, and they would show their happiness in the form of a large gift for him when he passed all the honesty tests. She said that they had already begun the honesty tests and so far, Dilip had passed two tests with flying colours. Their confidence in him was palpable.

I flung out my hand to meet Dilip’s in a “high five.”

“Great. Great, fantastic!” Seizing the moment, I asked, “Are you feeling the effects of having a more honest reputation?” The restoration of an honest reputation is proposed in place of the refutation of stealing.

“Yes,” he replied confidently.

“And tell me, how would you say having a more honest reputation has affected you?” Dilip’s reply surprised me.

“Well, I am allowed in the garage now. I haven’t been allowed in there for a while which was really hard because that’s where I make things. My parents said I couldn’t go in there because of the stealing. Now I am making a steamboat out of oil cans. Arthur has lent me a soldering iron.”

I said, “Okay, would it be fair to say that your honest reputation is winning back your parents’ trust in you?” Dilip’s expression said it all as he shot a shy smile at his parents whose faces were already alight with pleasure.

I asked, “What’s it like for you to know that your parents’ trust in you is growing as your reputation for honesty is growing?”

Dilip replied that it was good. Eager to capitalise on the growing trust by naming the pride on all their faces, I asked “Are you feeling a little bit more proud of yourself?”

“YEAH.”

Comparing the present pride with the sadness of our first meeting, I

Psychotherapy Behind Prison Walls. Does it Really Help?

Posted on by Psychotherapy.net Team

Despite working in the field of corrections for the past seven years and in mental health for ten, there are still aspects of this work that I find jarring. One of the most distressing elements of my work is when working with individuals who have been diagnosed with Autism or some form of neurodevelopmental disorder in which their thinking and relating is impaired. Oftentimes, these clients present as adults but function at a prepubescent to early adolescent level, all while being confined to an environment with other adults whose intellectual functioning remains age-appropriate. This is the equivalent of placing a juvenile with an incarcerated adult.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

I wish that I could say that my experience in working with these individuals has been limited, but the sad reality is that this is an area in which I have unfortunately become well-versed. Not understanding social norms, the criteria for healthy relationships, the importance of consent, and boundaries have been the most common characteristics shared by these particular clients. The challenge of working with these neuro-atypical individuals within the prison setting centers around discussing and helping them address issues of sexuality, not only their own, but as they impact relationships with other inmates who are often far more sophisticated, opportunistic, and at times predatory.

I’ll never forget the day I met Ronald (a fictitious name) because my immediate thought was, “How did we get here?” Ronald functioned much lower intellectually than his stated age, and as a result entered the penal system after misunderstanding social and relational cues. Ronald was then admitted for more specialized treatment after he was taken advantage of while housed in the general population setting. This is not uncommon when impaired individuals like Ronald live side-by-side, day-to-day with others whose primary interests are their own needs, oftentimes sexual. Ronald would often parrot the phrases he heard from other residents, even when they were racially charged or otherwise provocative. He didn’t do these things because he was prejudiced, but because doing so was a symptom of his condition and something that he often did when he felt uncertain of how to fit in. He would then begin emulating those around him that he perceived to be “cool.” In a correctional environment, this is particularly dangerous because it often results in the neurodivergent individual’s being either severely assaulted or deliberately used as a pawn to antagonize someone else or a group of individuals.

Another challenge I’ve noticed with these individuals is when they openly discuss or share their money or possessions without making sure that either or both are returned or made good on in some fashion. Ronald struggled immensely in this domain, as he would often buy things for others who would never return the favor and who wanted to take as much from him as possible. Fortunately for Ronald, staff members became aware that this was occurring, and he was moved to a smaller pod with a focus on psychiatric well-being.

In this regard, the best that neurodivergent individuals entering correctional environments can hope for is attentive staff members and genuine peers who look out for them and help protect them from becoming victimized or taken advantage of. Unfortunately, these helpers are not omnipresent, leaving these residents vulnerable for no other reason than their difficulty interpreting social cues and relating to others who would intentionally hurt them.

I remember talking with Ronald about how he came to the psychiatric unit, and wondering aloud about his understanding of the situation. Ronald was not at all aware of the risks that existed in his peer interactions while in the general population, but did understand quite quickly that he felt more comfortable in a smaller, more specialized, protective unit. Treatment of Ronald has included basic social skills, education around the topic of consent, and continuously openly discussing what a healthy versus unhealthy relationship looks like. Ronald was very clear that he had never before had such discussions, which solidified for me the importance of ensuring that people who are neurodivergent are not left out of conversations that have to do with sexuality. Therapists in the carceral system can be life-altering for these individuals when they take the time to go over the “basics.” It is critical that we put our own egos aside and look at the ways we can be most effective with these particular clients, rather than quibble over which therapy or technique is more effective than the other. When I have opened myself to creative treatment interventions that addressed the developmental needs of my clients, I have done some of my best work and influenced these clients in unexpected and at times very wonderful and rewarding ways.

The treatment unit where I work strives to provide a close knit, therapeutic milieu that allows for individuals with major mental illness and neurodivergence to feel safe, cared for, and to receive the highest possible quality of care. And this has happened when I haven’t been afraid to step outside of the box.  

Listening for Meaning in the Voices Nursing Home Clients Hear

Posted on by Psychotherapy.net Team

Several years ago, I worked with a lovely lady in her early seventies who resided in a nursing facility, and who heard the voices of her daughter and son daily. She had been delighted to be a young mother of two children but was ill with bipolar disorder and psychotic features that necessitated repeated psychiatric hospital admissions. Her husband subsequently divorced her, gained custody of the children, and remarried. The children bonded with the stepmother and cut off all contacts with their biological mother. One day I asked her, “If we had a new pill that would eliminate all voices, would you want it or not?” “Oh, no, Tom; then I’d have no contact with my children,” she answered.

Different Kinds of Voices

Over the next few years, I asked that question to hundreds of therapy patients in nursing facilities. I had initially assumed that most persons who hear auditory hallucinations would like to turn them off completely. To my surprise and increasing fascination, the majority, approximately 70–80% of those that I asked said no, they would not take a pill that would erase all voices.

Individuals with whom I’ve worked therapeutically have explained that there is indeed a negative aspect of the voices, usually involving insulting and hurtful remarks, but there is also a positive aspect—something that was pleasing, and they would not want to do without. For each person, the positive element was different, and was personally meaningful. “Tom, if it wasn’t for the voices, I’d be very lonely,” said a woman in her fifties with schizophrenia.

“I’d have no one to talk to if it weren’t for the voices,” said a male patient.

“I don’t really talk back to them, but I like them, and I listen to them; and it’s better than talking with people,” said a 73-year-old man with schizophrenia.

“I guess it’s a side benefit of schizophrenia: I can hear the voices of my dead relatives,” said a male patient.

“The good voices I think of as the children, and the bad voices are the adults; I’d just feel terrible if I stopped hearing from the children; they cheer me up,” said a different female patient.

“It’s easier talking to the voices than to people,” a man said.

Some believe they gain special knowledge from voices. “How else would I know what’s going on?” one man asked. “I read people’s minds; I can tell what they’re thinking because I can hear it.”

Some patients, though, do wish to eliminate all auditory hallucinations, and their psychiatric medications do offer symptomatic relief. Some patients tell me that they used to hear voices, but no longer do because of their medication.

Some individuals with whom I’ve worked have achieved insights through psychotherapy that helped them understand and manage the symptoms. I worked with a 74-year-old woman who had more than a 50-year experience of schizophrenia. She knew the name of the condition yet could not recall ever being educated about the symptoms of the illness. She believed that she had super hearing and could hear persons in different rooms saying nasty things about her. Often, she would yell out when passing by the nurse’s desk—because of hearing the nurse making insulting remarks about her. After months of therapeutic conversations about voices as symptoms of schizophrenia, she greeted me one morning by saying, “Guess what happened today, Tom? I was walking past the nurse’s area, and I heard them talking bad about me, and I realized; I’m hearing it, but they are not saying it!”

Troubled Journeys

Multiple factors might cause or contribute to one’s hearing an auditory hallucination—they can be associated with neurologic conditions, seizures, autism, bereavement, medication effects, drug effects, trauma and dissociation, borderline personality disorder, dementia, and/or postpartum psychosis. But for persons with a diagnosed psychiatric condition who hear voices, there may often be a pattern of additional, related life experiences that can further limit social functioning and productive activities.

Many patients who speak with me in psychotherapy about the voices they hear also report early-education learning difficulties, special education classes, and a growing sense in childhood of being different, with estrangement from peers and few childhood friends—and, therefore, reduced opportunities to develop and refine social relationship and communication skills.

Autistic elements are commonly identified in schizophrenic illnesses. Learning disabilities, likewise, are commonly associated with schizophrenic illness. Autistic features, learning disabilities, and mental illnesses can contribute to social estrangement and reduced development of adaptive social communication skills.

Affected persons may withdraw into substitute communications with voices, and that can in turn contribute to worsening of symptoms of depression—as can be manifested in the menace of some perceived voices—and to progressive depths of withdrawal, thereby adding to paranoid distrust of others.

My clinical experience suggests that many patients rely on an imaginary companionship through the voices and would like to minimize or eliminate only the malignant (the derogatory, or depression-reflective) voices. Yet other persons report significant relief when their experiences of hearing voices have been quelled by medication. If those persons had been asked prior to remission of auditory hallucinations/delusions (AH/D) symptoms, might they, too, have said they would prefer to retain the voices? I believe that relief from symptoms would better serve an individual than a pseudo-accommodation to them.

The Gifts of Therapy

I think there is a vital need for new and more effective medications, and for optimum application of presently available medications, along with psychotherapy and psychosocial interventions that can be applied by staff persons in the nursing facility.

Sometimes one learns in unexpected ways that a patient is experiencing hallucinations. I worked with a 48-year-old man with a diagnosis of bipolar disorder and no known experience of hallucinations or other psychotic symptoms. He often complained of pain and argued with staff persons. He was making vague remarks about something bothering him one day, and among other questions, I asked if he ever heard voices in his ears, anticipating he would say no. He surprised me by saying, “Not in my ears, I hear voices in the mattress; I hear the voices of the dead people who died on the mattress before I started using it. That’s why I don’t sleep at night.” The physical frailty that brought him to the facility for nursing care and rehab triggered underlying fears of dying.

Images in dreams typically hold specific and personal meanings that can be identified through sensitive personal conversation, and awareness of those meanings can improve a person’s understanding and coping with internal experiences. Hallucinations and delusions likewise contain personalized meanings and tend to provide protective psychological functions. Symptoms can be remarkably clever psychic creations that help balance an imbalanced psyche.

Many persons who don’t have a mental illness might entertain glorious daydreams of special accomplishments. Some persons with a psychiatric diagnosis develop grand delusions that protect against feelings of shame and disappointment over inadequacies. A 54-year-old man with schizophasia and thought disorders due to schizophrenia who found it difficult to communicate in ordinary ways with others once told me he had written the lyrics for many of the major rock bands.

Sometimes a patient will openly discuss their hallucinations during therapy yet deny having them when questioned by other care providers. “That was a red flag for me,” a 54-year-old female patient said about an initial conversation with a psychiatric consultant asking assessment questions. “I didn’t know who he was, and he was asking these personal questions, so I hardly said anything.”

Some patients say they do not report their internal (symptomatic) experiences, such as hearing voices, to other care providers because “they might not believe me,” “they might think I’m crazy,” “they might just think it’s not true,” “they might make fun of me,” or “they might send me to the hospital.”

I explain that in psychotherapy we are looking for the true personal meaning of the experience, so that they might better understand and manage those experiences—and, for persons hearing voices associated with dissociative conditions, so that they might better integrate the meaning of the perceptions. In therapy we talk about the difference between objective reality and subjective reality, so that the person might feel less perplexed and afraid, and more willing to discuss and examine their experiences.

The Other Side of the Sun

I met for weekly psychotherapy for two years with a 53-year-old man with schizophrenia who told me one morning, “I just got back to earth. For the last 30 years I was living on a planet on the other side of the sun.” He was upset because the staff had laughed and told him it was not true when he told them earlier that morning about his experience. I spoke with him about things that are true as shared realities and things that are true as psychological experiences that have symbolic personal meaning. We spoke of ways he wanted to fit in and get along with others, yet how that might be difficult and how he might sometimes feel far away from others. So far that it would be like being on a different planet; and how good it feels when one starts to feel better, and back down to earth, and better able to connect with people. This conversation helped him to speak more directly about the alienation he sometimes feels because of his illness.

In psychotherapy, some patients argue that the brain is not capable of creating convincing experiences that are not real. The following remarks represent a composite of conversational points from sessions with a few patients.

Therapist: Have you ever awakened from a dream and thought, wow, that dream was so real!

Patient: Yeah.

Therapist: And where did the dream come from?

Patient: Okay, it came from the brain, I see.

Therapist: Have you heard of someone taking LSD?

Patient: Yeah.

Therapist: What happened during the “trip?”

Patient: Oh, yeah; they heard things and saw stuff, and maybe went to another world.

Therapist: Those seemingly real experiences were caused by a chemical that triggered an imbalance of other brain chemicals.

Patient: My psychiatrist said my illness was a chemical imbalance in the brain.

Therapist: And psychiatric medications work to correct imbalances of brain chemicals.

Patient: Oh, so brain chemicals can make you hear and see things that are not there, except in your brain.

Therapist: Do you hear a high-pitched ringing sound?

Patient: No.

Therapist: I do, because I have a condition called Tinnitus. The ringing is not coming from outside of me, but from inside, because of a medical condition. It is subjectively real, because only I hear it. It would be objectively real if we both heard it at the same time.

Patient: Okay, so some things can be real for me on the inside, but not real between you and me; I guess that’s like mental illness.

Asking the Right Questions

Assessment questions using clinical terminology might trigger anxiety and reluctance to acknowledge internal perceptions and beliefs. “Do you hear auditory hallucinations?” might trigger a denial, yet asking “Do you hear voices or receive communications that are pleasant, unpleasant, both or neither?” might initiate conversation about one’s experiences. Asking if one feels paranoid might stir resistance, yet asking “Is it sometimes frightening or confusing to deal with people?” might lead to conversation about the thing’s others do that cause fear or mistrust.

What do auditory hallucinations compensate for? What do they replace? Do internal or out loud conversations with these voices represent a form of self-treatment for the patient? What type of adaptive skill training might address those needs?

Turning to the literature does not always result in answers to these enigmatic questions. I believe that additional research is needed to:

  • Improve awareness of the incidence of AH/D amongst persons with psychiatric diagnoses residing in nursing facilities
  • Identify how many patients have achieved remission of AH/D resulting from psychiatric medication
  • Determine how many persons experience auditory hallucinations without delusions
  • Identify the percentage of patients preferring to retain rather than eliminate AH/D
  • Elicit examples of personal meanings of AH/D
  • Develop educational guidelines to assist Activities Department staffers, including occupational and physical therapists, to teach and practice adaptive social communication skills
  • Gather ideas/suggestions from patients on how professionals might inquire about symptoms without causing shame or triggering denials

***

I have been and continue to be deeply moved by the trust and disclosures offered to me by the many vulnerable persons with whom I have been privileged to work. I ache with hopes that we find new ways to quiet their symptoms, relieve their shame, and help them deepen their willingness and capacity for ordinary social communications.

Laurie Helgoe on the Power and Challenges of Introversion

Posted on by rezendevknowfully.com

An Inner Laboratory

Lawrence Rubin: How would you, as a person, a clinician, a researcher, and a writer, define introversion?
Laurie Helgoe:
if you think of where you do your processing, where you work things out, where your laboratory is—it’s internal for an introvert
Introversion at its simplest is an inward orientation. If you think of where you do your processing, where you work things out, where your laboratory is—it’s internal for an introvert. In contrast, the extrovert’s laboratory is more external, and this difference translates to a lot of things. Introverts go inward to think things through. If there’s a question to be answered, like the one you just asked me, I might pause and kind of go inside myself to try to work out the answer before I speak. An extrovert might do that work interactively by giving you a partial answer and then engaging you in a back-and-forth until that answer is fully worked out. There’s not one “right” way, but the challenge for an introvert is if there’s not that space to go inside.

So, there’s a lot that goes with that. Many introverts talk about feeling energized through solitude. Part of that is just because they don’t have anything intruding on their thought process and kind of relax into it more easily.
LR: Being energized through solitude is interesting because we seem to live in a society in which we’re taught, or encouraged, or modeled, to seek energizing through connection, through activity, through accomplishment, through the immediacy of social media. So does that inherently place introverts against the current in our society?
LH: I think so, and that is why many introverts end up feeling bad about themselves or feeling that there’s something wrong, because we have these portrayals of the fun in life, the energizing aspects of life, as being social. I remember when one of the major phone carriers had this “friends and family” ad where one person was surrounded by this mob of people. That just sold me because it did just the opposite of what it intended because that looked like hell to me. Somehow, having that easy connection with this mob of friends and family was supposed to be what people wanted. And then when I think of the sitcom Friends, which just had a reunion show, there was the idea that people could just randomly pop into my space and I would always enjoy having them on the couch.

I think there are a lot of ways that introverts wonder things like, “Why aren’t I having fun at this party?” and “Why can’t I wait to get home and have what is considered fun for me?”
None of that fit for me, so I think there are a lot of ways that introverts wonder things like, “Why aren’t I having fun at this party?” and “Why can’t I wait to get home and have what is considered fun for me?” And in their case, that would mean getting back to a great book, or walking their dog, or just reading with space around them.
LR: I go back to that interesting analogy you made of the introvert having this internal laboratory. Is that contrasted with the extrovert, whose laboratory is the stage rather than a private enclave, and if so, does the introvert shy away from the public stage because that’s not where they process and how they process?
LH: Right. That’s an interesting question, because I happen to enjoy acting and I’m an introvert. But I think, and this is what reveals the complexity of introverts and extroverts, is that each may have different aspects, different ways in which people are introverted or extroverted. For example, public speaking is a common fear that is not confined to introverts. There are many extroverts who are terrified of public speaking despite the interest in and programming for obtaining external rewards—to get those smiles, to get those responses from others. In fact, there are dopaminergic pathways that reinforce external rewards, and these light up for the extrovert when they are socially stimulated.

I think introverts like me who enjoy the stage like teaching, acting, and performing in front of others, and particularly like the fact that they can do it in a structured way
There are fMRI findings and studies which show that introverts respond pretty much the same to images of flowers or people, whereas extroverts are very much more responsive to people-related stimuli. But while these positive, people-related stimuli can engage extroverts, they can also distract them from seeing the whole picture. Extroverts can in a way distort reality toward the positive because they really like these people-related rewards. It would be an extroverted kind of characteristic for someone to like the stage. That said, I think introverts like me who enjoy the stage like teaching, acting, and performing in front of others, and particularly like the fact that they can do it in a structured way, one that they planned and practiced for as opposed to being put on the spot. This is because when introverts are put on the spot, they don’t have time to go to their laboratory.

Misconceptions

LR: I’m fascinated by the notion of the inner laboratory—it has almost an Eastern sound to it. This makes me wonder if the so-called “extrovert ideal” is more of the dominant Western narrative, and that the benefits of introversion have only recently been recognized along with mindfulness practice and the integration of Buddhism into the clinical landscape.
LH:
in Eastern cultures, it can be the opposite, where extroverts are seen as a little weird or really out there
It’s so interesting you raise that, because there has been a lot of research suggesting just what you’re saying, which is that there is a very strong bias toward happiness in our culture—but a specific kind of happiness. Even the studies that have shown extroverts to be happier only tend to look at one facet of happiness, which is a high arousal-positive affect. But the research doesn’t look at low arousal-positive affect such as feeling tranquil and at peace, the chill feelings that are more valued by introverts. And so, you have this kind of culture-personality mismatch, which can lead introverts to feeling badly about themselves. In Eastern cultures, it can be the opposite, where extroverts are seen as a little weird or really out there. And there’s a puzzlement about this so-called American (extrovert) personality. So yes, I think there is some balance that is slowly being introduced as we look toward and value more contemplative practice in our society.
LR: Since we are this doing-connecting-running-accomplishing-externalizing type of culture, what misconceptions do clinicians need to know surrounding introversion and the introvert, such as the introvert and the schizoid personality are similar?
LH: I’m sure you were attuned to this when the DSM-5 was in development, but there was a proposal on the table to include the term “introversion” in a number of diagnostic categories as an indicator, as a symptom. But there was a loud outcry to that because what really was being referred to in the DSM was a kind of disengagement, and the problem with seeing introversion as disengagement is that it’s actually just the opposite. A healthy introvert may be quiet in a conversation, although not all introverts are disengaged. There is a continuum. Oftentimes, the reason why introverts are quiet is because we ARE engaged, because we’re processing, because we’re trying to make sense of what the other person is saying rather than the opposite, which is disengagement. We may put on good poker faces so that it seems that we’re kind of schizoid or not there. And sometimes introverts do need to make the point of narrating our process. Saying “Yeah, I’m thinking about this, just give me a second.”

so this idea that introversion is a pathological indicator is extremely problematic
So this idea that introversion is a pathological indicator is extremely problematic. I think most people who study introversion and extroversion see them as neutral categories and that there can be problems associated with either. If we look at mental health disorders, some of the impulse control disorders like substance use are more prevalent in extroverts, whereas for introverts, the internalizing disorders like depression and anxiety can be more prevalent.
LR: I am reminded of the Achenbach scales, which suggest that the externalizing disorders are more typically relegated to men and the internalizing disorders, like depression and anxiety, are more common among women. So, I wonder if there is a gender line that also contributes to the introversion/extroversion schism?
LH:
women have a harder time getting permission to be introverted
The gender differences aren’t as great as you might think. While I don’t have those figures right in front of me, one thing that’s notable is that women have a harder time getting permission to be introverted. We tend to think of the man as the strong, silent type, whereas a woman might just be considered the B-word or a snob if she’s not engaged. We have a lot of expectations on women to be the social kind of glue in our society. I think actually men are a little bit more prevalent in terms of the numbers, but they are not that different.
LR: I think I might have jumped ahead of myself. Can we go back and discuss other misconceptions around introversion?
LH: So, I think one is that there’s some kind of pathological disengagement. Another one is that introverts are shy, which is probably the most common misconception. While introverts can indeed be shy, so too can extroverts. The way that introversion is classically understood is that we are internally oriented, and our social way of engaging may be a bit different. We like a little more space in our interactions. We probably like fewer people. But all of that comes back to the level of stimulation. And I think of Hans Eysenck's level of cortical arousal and the idea that the sweet spot for everyone is in the middle, where we’re not too stimulated and we’re not bored. But extroverts tend to get cortically bored. They tend to crave more stimulation, so they’re trying to move in the direction of more stimulation to get to their middle, whereas introverts are trying to tone things down more to get to their middle.

So, for example, I’m at a party and I’m with a shy person. I, being pretty socially introverted, might be hanging on the sidelines because I kind of like being there. And there’s probably somebody there who’s a little quieter who I might want to talk to. I might really enjoy observing or just taking a break. A shy extrovert standing next to me might really, really want to be in there and just doesn’t know how. There might be a lot of self-consciousness and that kind of thing. Now again, these variables can overlap, but I think it’s much more helpful to see them as separate.
LR: This may be the pushy extroversive side of me, Laurie, but can you think of any others before we move?
LH:
there’s even a misconception or assumption that introverts really don’t have a personality—you know, that they’re kind of bland
Another one is that introverts are snobs. And this again might be due to the poker face. In the U.S., we love smile emojis, and we expect this very exuberant, outward-oriented evidence that a person is engaged, or present, or responsive. And if we don’t get that, the readiness is to assume that that person maybe doesn’t like me or is non-approving and stuck up. There’s even a misconception or assumption that introverts really don’t have a personality—you know, that they’re kind of bland. But if you just took a peek inside the laboratory, you’d find otherwise.
LR: I don’t know if this is a misconception, but there’s been a little bit of buzz in the literature about the overlap in some ways between introversion and autism. Is that a dangerous connection to make clinically?
LH: I know there has been talk that introversion is like [what used to be called] Asperger’s. I think if it helps us understand the autism spectrum in a different way, it may be useful. But I don’t know that it is the case and honestly, I haven’t gone that direction myself because we’re trying to link something up that may not be helpful and could be quite the opposite.

I’m all for the direction of us de-pathologizing most things, right? I think there is agreement around communication difficulties associated with autism spectrum disorders and there may also be some for some introverts. There may be some ways in which the spectrum would explain some aspects of their behavior.

LR: I can see what you’re saying in terms of this societal tendency to pathologize anything that’s considered different. We just tend to “other” the hell out of each other, so clinicians need to be very wary of looking for or building connections between introversion and pathology or problematic issues based upon misconceptions.

Introverts and COVID

LR: How did introverts fare during the isolation and social distancing of the COVID pandemic—heaven or hell?
LH: In fact, I was just looking at some recent findings on that, and introverts did for the most part thrive, although there certainly are variations. While extroverts had a hard time, with reported deterioration in their mental health, there were certain challenges that isolation created for introverts. Surprisingly, there was a time in history where all of a sudden, introverts were being asked, “How do you do this? How do you manage being alone? How do you manage this?” So, if nothing else, I think there was a sense that what we have is valued and has survival value—because we did. We all were safer because people stayed in their zones because they were able to socially distance themselves and to spend more time alone.
LR:
so, during this time of forced isolation, those who have historically been quite fine with solitary and internal lives became the experts in teaching the rest of society
So, during this time of forced isolation, those who have historically been quite fine with solitary and internal lives became the experts in teaching the rest of society. You mentioned the word “thrive,” and that introverts were called upon for their expertise.
LH: I can use myself as an example. I am still mostly working from home, where I teach and work with a lot of students. In my traditional face-to-face classrooms, we have an open office plan, which does not necessarily work well at all for having conversations and is overstimulating for introverts. But what is paradoxically true for me and others of my colleagues is that from home, I now engage better because I can have a conversation on-screen with a student or a colleague from the quiet of my home office. I don’t have to worry about privacy or having to find a special room because of that open floor plan. From home, I can be in a place that reflects me—we might even talk about my paintings that are sitting behind me or the view outside the student’s window, which might be snow, while I’m in Barbados. We get to connect in a more personal way because we have this home-to-home kind of connection. So I have actually found that this forced isolation has enhanced my relationships, because they have become a little more contained and kind of safe in cyberspace.
LR: Is safety a concern for introverts? And as I even ask the question, I wonder if some clinicians out there are wondering if this need for safety suggests some kind of earlier trauma.
LH:
introverts tend to be more guardians of privacy
What I mean by safety is the freedom from bombardment and overstimulation, but it can also mean the protection of privacy. Introverts tend to be more guardians of privacy, both for themselves and in relationships.
LR: Prior to COVID, I had a strict closed-door policy for that very reason, while other colleagues whose doors were always open seemed to spend far more time gabbing than working. Did you find any other differences in the ways that introverts and extroverts fared during the pandemic?
LH: One thing I know from academia is that there’s evidence that everybody’s working more since we’ve gone online. Introducing new platforms and having a lot of Zoom meetings can definitely result in social fatigue when you’re constantly on screen.

the introverts I know who have struggled the most are the ones who have extroverted family members at home
But the introverts I know who have struggled the most are the ones who have extroverted family members at home, or kids that they are locked in with and from whom they normally get a break from. I know I’ve missed some of my introvert haunts, like the coffee shop I go to work and the movie theater. I like places in the world where I can be quiet and where I can view, you know, kind of be a flâneur (I wish we had an English word equivalent). I like the idea of the passionate observer who is out and about, but not engaged in a direct way—I do get energized by that. So, I think there definitely are ways in which introverts have missed out. And certainly, we have close relationships, so it’s been very hard to be separated from family and friends, because introverts are not necessarily loners. I’ve talked to introverts who have grieved a loved one who they described as their “comfortable person.” For introverts, it’s hard work to do small talk, so we rely more on our comfortable people.

LR: And I would imagine that older people who have historically been accustomed to face-to-face contact don’t find the same level of comfort on the screen.

In Therapy

LR: I don’t imagine that people come to therapy because they are suffering from introversion. And while I was initially going to begin by asking about the challenges that introverts bring to therapy, I’d like instead to ask how therapy can tap into the strengths and resources that introverts possess?
LH:
analysis was a space where I could sort out the fact that I was at odds with the way my lifestyle was set up and how it wasn’t working for me
The first thing that came to mind when you said, “Introverts aren’t necessarily going to come in and say I’m suffering from introversion,” was that they might in some way say, “I’m suffering from society,” which is what was going on for me when I went through psychoanalysis. I talk about it in my book and how it really was the starting point for the book and for a lot of healing for me. Analysis was a space where I could sort out the fact that I was at odds with the way my lifestyle was set up and how it wasn’t working for me. It was important to finally put a name to it—that I was an introvert. I realized that I needed things that my life wasn’t providing, so I started to make some radical changes in my life.

So in therapy, you might have people saying things like they are getting hassled at work because they’re not outgoing enough, or who feel bad about themselves because they are at odds with society. It can be very, very helpful for clients to be able to put a name to it. I can point to so many people who have talked about that transformative moment when they said, “Ah, I’m an introvert. That’s why. Okay.” But, I think it typically depends on how that’s delivered.

That’s the beauty of a Myers-Briggs Type indicator, although some have criticized its psychometric properties. It really does describe each personality type in a strengths-oriented way, so people then can see themselves mirrored in that positive way. Instead of thinking that they are the problem that needs to be fixed, they have permission instead to engage in their lives in a way that works better for them.
LR: Do you ever feel compelled to point out to a client that they are introverted, or is that not always necessary?
LH: I would, and it may not even be that the word “introversion” is necessary. But I think it does help because there are a lot of characteristics that come with somebody who’s an internal processor. They might not think on their feet so well or they need space in conversations. If they have a spouse that always wants to do things or who always wants to talk, the introvert may wonder, “Why don’t I love my spouse or my partner because I don’t want to talk or do things all the time, and sometimes I want space for myself?” I might tell them, “Well, it sounds like you’re an introvert,” and they might say, “Oh, what’s that?” While most people know, I’m surprised that some people haven’t or don’t really reflect on being an introvert. I didn’t, and I’m a psychologist who didn’t really reflect on what that meant about me until well into my practice years.
LR: Do you find that it’s liberating for these clients once you tell them or suggest to them that they are introverted?
LH:
I get letters from readers all the time that say, “All I needed to know is that there really isn’t anything wrong with me, and there are other people like me.”
It’s tremendously liberating. I get letters from readers all the time that say, “All I needed to know is that there really isn’t anything wrong with me, and there are other people like me.” And there are people in our society who believe that the introvert is the rare person, kind of sitting down in the basement avoiding people, when in any given room introverts make up about half of the people in that room. So I think that knowing does shift a person’s thinking. They may finally understand, “That’s why I prefer to send an email than speaking my thoughts,” or “That might be why, after a meeting, I really feel like I need a break to think through what happened and write down some notes.” We get so much mirroring of what it means to be an extrovert, but don’t get that much about what it means to be an introvert.
LR: Would you necessarily treat a depressed, anxious or perhaps substance-abusing introvert differently than you would treat a non-introvert with similar symptomatology?
LH: I think a lot of the treatments apply well to both. But I think that for introverts, part of our treatment is to help them align their lives with what gives them joy, even though we need to be very careful about ascribing to them what we think that would be. That would be like the parent saying to the child, “You need to go out more to be with your friends,” when maybe that child simply relishes reading a book and living in this wonderful imaginative space. The parent would end up trying to pull that child out of that comfortable and happy place and telling them what their definition of happiness is. Similarly, we have to be very careful as therapists to not impose what we think the introvert’s happiness should be.
LR: I could see an overzealous introverted therapist trying to impose their expectations or beliefs on a client; sort of introversion-based countertransference?
LH:
introverts tend to be quite versatile because we bend and have to be psychologically bilingual, which is actually a strength
If the therapist had some kind of mission, that could definitely be a trap, because we do know that introverts can gain a good feeling through social engagement. Even acting like an extrovert can give you a lift. I think the difference with introverts is that it can be helpful for them to know about their introversion without feeling like they have to change who they are. Introverts tend to be quite versatile because we bend and have to be psychologically bilingual, which is actually a strength. It’s easier for introverts to act like extroverts in general than it is for extroverts to act like introverts. We saw this with COVID. It was not easy for those extroverts to flex in the introverted direction, while introverts have had to do it all their lives. Through my book and my activism, I have wanted to simply reinforce the idea that introversion is a viable option. That’s not to say that introverts have to be introverted all the time or that they won’t benefit, but the problem is that many haven’t gotten permission to be who they are in the first place. So, if you’re not who you are in the first place, how do you transcend that?
LR: Are there any other challenges or issues that introverts are more likely to bring to therapy?
LH:
maybe we introverts are entitled to a little bit of that juice that the extroverts are drinking
I think introverts, for better and for worse, can be self-scrutinizers. We are reflective. We think about our conversations. We reflect on events. And so, that may give us a more realistic view of things, and it also can induce anxiety and depression. I think this is where mindfulness techniques are so helpful—we can do that reflection without getting so attached to those thoughts and, as a result, can come back to the present. And at times, we can deliberately seek those joyful experiences and do what extroverts do. Maybe we introverts are entitled to a little bit of that juice that the extroverts are drinking.
LR: In addition to mindfulness, are there particular modalities of therapy that introverts might be more drawn to?
LH:
a very extroverted therapist who really wants a back-and-forth kind of dialogue may lose an introverted client
As an introvert myself, I always gravitated toward the psychodynamic psychotherapies in part because they provide so much space for the internal life. As number nine in a family of ten who was constantly overstimulated, I relished the luxury of having a person listen to me in a place where I got to lay back on the couch and just let my mind take up the whole room. In terms of space, that was a wonderful thing.

Not all introverts would necessarily like that. Some introverts do actually appreciate some structure or inquisitiveness from a therapist. I think that a general rule is that when working therapeutically with an introvert, there needs to be a certain level of patience to let the client consult with their inner laboratory and find out what they’re thinking. A very extroverted therapist who really wants a back-and-forth kind of dialogue may lose an introverted client.
LR: What about the opposite situation in which an introverted therapist has a very extroverted, performative, gregarious, energetic, over-stimulating client?
LH: I’ve actually had to contend with that because for me and a lot of introverts, interrupting is taboo. But some extroverts expect to be interrupted. They kind of like just letting go and knowing that you’re going to get your word in whether you want or not. Some extroverts love talking to introverts because the introvert gives the full space. But the introverted therapist may also have to be more active than they prefer with that type of client.
LR: I closed my physical practice a few years ago. It was so highly personalized, and some might argue overstimulating. If you were to be a consultant for designing therapy spaces for introverts, what tips might you offer?
LH: I love that question, because I think it’s a neglected one. One thing is that introverts are already likely coming into your office over-stimulated. If you have bright lights and a lot of clutter in your office, you’re probably not going to have somebody who’s going to be very able to settle into the space. I am very attentive to lighting so have a softly lit space, and because some introverts may not always want to make eye contact because they have to think and because sometimes our eyes will distract them, I do have some things that allow the patient or client to look away from me. They want to be oriented towards you. Introverts tend to be very absorbent of what’s going on around them. And so, they almost need to close themselves off. So, not facing the chair directly at them is helpful—kind of fanning them out so that the client can look off and go inside instead of always looking at you but can also easily enough look over at you. That kind of thing can really make an introvert feel more comfortable and open in this space.
LR: Maybe we can go into the office setup-for-introverts feng shui business.
LH: Love it.

Introverts at Home

LR: Do introverted parents bring unique challenges to therapy?
LH:
parents don’t often give permission and encouragement to help their child develop solitude skills
I do think parents feel a lot of pressure, from the whole playdate revolution, to having the most fun birthday party. I remember, and say this with a little bit of shame, but I was always relieved after Halloween was done because there was this pressure to create the best costume. One thing that I always note is that parents feel such a responsibility to help their child develop social skills, and certainly that is an important coping mechanism. But parents don’t often give permission and encouragement to help their child develop solitude skills. We can’t always entertain them. And if we are, we are developing a child who doesn’t have much resilience, because the reality is, we’re going to be alone for a good part of our lives. So, I think that it is important to help both introverted and extroverted parents foster that quiet space for their child(ren).

I remember the psychotherapy theorist, I think it was Fred Pine, who talked about the importance of quiet pleasures. Winnicott also talked about that. I like the idea that the child and you can be doing parallel things in this quiet space, and that child internalizes the ability to be alone, because they learn that they can be alone together. They learn that there is a sense of somebody who can tolerate their aloneness, which I think is such a beautiful but rare thing in parenting. That we can just do nothing together?

I was just watching the movie Christopher Robin. I love the way that Christopher Robin and Pooh talk about doing nothing because when you do nothing, something happens. I love when somebody asks me what I’m doing, and I say nothing, and then I do it. It is the idea of the generative, the fertile void. The way that boredom is a precursor to creativity. So I always ask, are we allowing kids boredom? If parents took some pressure off themselves to stop entertaining kids, kids might paradoxically end up being more self-entertained.
LR: I just wrote the introduction to a friend’s book on nature-based play therapy, and as we chat, Richard Louv’s work on the importance of nature in child development rings so loudly in my ears. I think kids (and adults) need to be in nature where there is quiet, and there is awe, and there is, like you said, an external space where they can be internal.
LH: Yes. I find for myself that having an evening walk when things are quiet is when I do feel that the laboratory is wide and vast, and I don’t have to tuck it away.
LR: Moving from parenting to relationships, what challenges have you found working with couples who are mismatched temperamentally?
LH:
an introvert/extrovert couple are going to have more conflict if they are going to be close, because they need to negotiate
I think there are a lot of introvert/extrovert couples that do quite well. But knowing from experience, an introvert/extrovert couple are going to have more conflict if they are going to be close, because they need to negotiate. So, if the extrovert wants to go out and be with friends, how often will the introvert be willing to do that? The introvert may indeed want to go to a movie or just have a quiet dinner or just stay at home and read together, which is a legitimate date, in my opinion.

There can be real advantages to that, because we might appreciate at times being pulled out of ourselves. Or pulled in, pulled back from ourselves. And so a couple that represents both those functions can become flexible in that way. What I notice is that there may be more of an ease in introvert/introvert couples. But that may also come with a lesser growth curve. The other thing can happen, though, is like with systems therapy, where one plays more of the function of introvert or extrovert. So, you have all different variations on the theme. But I think that naming this process becomes important in clinical work with couples, especially if their temperaments put them at odds. It took my husband and I twenty-five years and the writing of my book to discover that when I’m quiet, I’m not telling him he needs to explain things more.
LR: Or that you’re not withholding something from him or pushing him away.
LH: Instead, that he has been understood, and that I’m not telling him that I am disengaged. I’m actually thinking about what he says. So now when I’m quiet, he’ll say, “Oh, you’re thinking about it, right?” And I’m like, yes.
LR: So, your book in part was a marriage survival guide for yourself?
LH: Yeah, it’s very interesting to me that after writing the book, I found applications in my own life that I hadn’t yet discovered.
LR: Well, you probably were aware of those, but not consciously because you’re an introvert. They were bubbling up in some beaker deep in the back of your laboratory.
LH: There you go.
LR: As we come to an end, Laurie, what would you leave those clinicians out there who haven’t yet given too much thought to this whole introversion/extroversion area with?
LH: I think that we all benefit from having a richer world. And we have a richer world when we can embrace the internal and the external. I think too often we don’t, and we aren’t curious enough, or wait long enough to find out. I find in teaching interviewing skills to medical students that if they wait just a little bit longer, they’re going to find the story, the punchline, the meaning that, if they had spoken two seconds sooner, would have been missed. So keep in mind that the world is vast and wonderful out there. But it’s also vast and wonderful in there.
LR: If there are any questions that I wasn’t clear on, can I reach out to you after we finish today?
LH: Absolutely, because as an introvert, sometimes things get clearer later on.

Psychotherapy and Autism

Posted on by Psychotherapy.net Team

I just finished writing a book for psychotherapists on helping teenagers and young adults with autism. This topic does not get much coverage in the clinical literature on autism, as treatment books focus most often on children. This blog post will share some major points from the book. Autism is a neurobehavioral condition impacting social comprehension. It is often described as impacting “social skills,” but that is much too limiting. Autism impacts how an individual perceives the social world and interacts with that social world. Individuals with autism literally have a different way of perceiving social relationships, and they use skills they find appropriate given those perceptions. Autism makes up “who the person is” and not just “what the person does.” Having Autism makes up a major part of the answer to the all-encompassing question teenagers and young adults ask: “Who am I?” Therapists can help older clients take on this challenging question by helping them answer more specific questions like: “What does being a person with Autism mean?” “How do I want to live my life as a person with Autism”? “How important is it to have friends and what sort of friends do I want to have?” “How much am I capable of doing on my own?” “How much independence can I hope for?” “Where do I agree and disagree with my parents and teachers in terms of what they expect from me?” “How much do I care (and why do I care) about how people respond to my Autism symptoms?” Applied Behavior Analysis (ABA), the primary treatment approach used for autism, emphasizes learning skills to replace behaviors that are causing problems. ABA still plays a major role in treatment for Autism for teenagers and young adults. Using the questions listed above is an effective way of determining what skills the teenager or young adult needs to learn. So, for example, once your client has worked with you on what sort of relationships he or she wants, you can use ABA approaches to help them learn skills needed for obtaining those types of relationships. But what you are making clear is that you are not taking a “one-size-fits-all” approach to what skills to learn. You are not telling your client “You need to have friends” or “You need to do more with other people.” You are helping your clients decide what they want, even if it is different from what their parents, teachers or healthcare providers think they should want. Addressing disagreements between what young clients and their parents want from therapy can be a real barrier to progress. Everyone wanting to have the final say in what gets addressed can be more challenging with this type of therapy than any others. You have parents who are used to guiding their child’s treatment, and then the child (now a teenager or young adult) who is tired of being told what they should want or what goals they should have. This is even more of an issue with autism because childhood autism treatment requires heavy parental involvement. Backing off on this involvement, so that their child can have more say over what gets addressed, can be difficult for parents. I remember one client, a teenage girl with autism just starting the 11th grade, whose main issue was disagreements with her parents. Her goal was to interact with her peers more at school, but she was not particularly interested in more social activities outside of school. But her parents wanted her to do much more socially. They had another daughter who they described as a “social butterfly” who was often at parties and out with her friends. When they saw that their other daughter (my client) did not have much interest in parties, they determined that something was “wrong” with her and that her autism symptoms, which she dealt with all her life and had been under control for years, were causing her problems that she did not see. My client had considerable disagreements with her parents about this issue and was really starting to resent them for it. She was comfortable with her limited social activities and did not want to do much socially outside of school (but did want to do more socially in school). Her parents disagreed and we had to address this issue before deciding what direction treatment would take. This sort of disagreement is not uncommon for families of a teenager or young adult with autism. Given how intense autism in childhood can be and how involved parents often are, they may come to expect their child will not fully understand what they need from treatment. Having family sessions, where everyone is given their say but the therapist makes clear that the young client must be listened to, can help parents recognize the validity of their child’s views. It can also give the therapist the opportunity to talk with the parents about how there are different perspectives on what makes social relationships meaningful and what to expect from friendships. When I had the chance to discuss these issues with my client’s parents over two family sessions, they were more receptive to considering what their child wanted socially. They were actually initially quite angry at me for “giving in” to their child and treating her too much like an adult. It was only after we discussed these issues in depth, and everyone had the opportunity to express their views without interruption or criticism, that the parents were receptive to allowing their daughter to set the goals for therapy. Therapy for autism in the teenage and young adult years is more individualized than therapy for autism during childhood. One example of how this works out is that “social scripts” are used as opposed to “social stories.” Social scripts are based on discussions during the therapy sessions specifically addressing what the person wants in terms of social relationships and what situations they find most difficult in reaching social goals. Social stories, on the other hand, emphasize more general rules that are used across a variety of social situations. Many types of therapy approaches used effectively for treating different conditions for teenagers and young adults can also help individuals with autism. Mindfulness, cognitive-behavior therapy and relaxation therapy all have been found effective for treating anxiety, depression and anger comorbid with Autism. T client can learn how to use these skills to reach the social goals they set for themselves. Perseveration and self-stimulatory behaviors are common problems in autism that need addressed. They typically get addressed as clients identify the negative responses they get from other people because of these behaviors. Using the “Red Card/Green Card” exercise is one effective approach for this problem. Essentially it involves helping the person practice suppressing their repetitive behaviors by allowing them periods of time to talk about whatever they want (including perseverative topics) without interrupting them when the “Green Card” is up, in exchange for focusing on specific topics the therapist brings up when the “Red Card” is up. I have also found reviewing material related to the “neurodiversity movement” to be invaluable for helping determine effective ways of helping teenagers and young adults with autism. This is not a therapy orientation per se, but is a philosophical movement emphasizing that autism, along with other neurobehavioral conditions, is best thought of as a “difference” and not a “disorder”. Reading material related to this movement can give you a different perspective on helping make therapy for someone with autism as beneficial and individualized as possible. Reference: Marston, D. (2019) Autism & Independence: Assessments & Treatments to Prepare Teenagers for Adult Life. PESI Publishing & Media: Wisconsin.

Afflicted with Affect

Posted on by Psychotherapy.net Team

*Janelle sits on the edge of the loveseat in my office. Her knees form perfect ninety degree angles. She pulls her head up, her shoulders back and down, and looks me square in the eye with a set jaw.

The word “formidable” pops in my mind.

But immediately her shoulders curl forward, her head sags. “I want him to tell me how proud he is of me.”

The formidable woman suddenly sounds like a child.

“I raised over ten thousand dollars for pediatric cancer research last week.” She pulls herself up again. “He told me ten thousand dollars wouldn’t cover the cost of a single research assistant. He called it ‘trivial.’”

I work in a town with a large university and teaching hospital. A good portion of my clientele is comprised of the partners of physicians and professors. For a small subgroup of my clients, a common story has started to emerge.

“I was in grad school. I saw him at a party standing in a corner by himself. He looked so lost.”

The story goes like this: girl meets genius. A great guy. Well, truth be told, maybe a little less amorous than she would have liked, but a really great guy. She could tell he needed her: other people didn’t seem to be able to see past his awkwardness.

“I felt sorry for him. He just seemed so uncomfortable. Except when he was talking about his research. Then he’d get really animated.”

Girl marries genius: She manages her growing family, and more. She works on boards, does amazing fundraising, and volunteers for various charities.

As the family grows and thrives her husband pulls farther and farther away. At first she chalks it up to his demanding career. Then it becomes apparent that he really doesn’t like being at home.

At some point, the husband begins to criticize her emotionality, solicitousness, and superficiality. He blames her for being overbearing and boring.

These women are intelligent, well educated, and energetic. They all have very high social and emotional intelligence, which makes them highly attuned mothers, and the center of a large network of people and activities. All of which their husbands seem to resent.

Julie brings up a psychiatric referral. “Last week I tried to talk to my husband about our son. He won’t bring any friends around. He says his dad is too weird. Chip told me that he doesn’t want any more kids around the house, and besides, it’s probably because I’m so bossy.” Her eyes well. “I got angry. I yelled.” Her chin drops to her chest. “He told me that he can’t stand my histrionics. He asked me if my therapist knows how over-emotional I am. He said maybe I need some meds.”

It happens almost imperceptibly. Confident women begin to doubt themselves. They have been repeatedly told that what makes them inferior to their brilliant husbands is that they are afflicted with affect. If they could be rational, perhaps they wouldn’t be so intolerable. By the time they see me they believe that their emotional intelligence is a sign of weakness, or worse. They want me to cure them from having feelings.

It took me quite a while to figure out that a significant subset of my clients were married to men who were very high functioning on the Autistic Spectrum. It seems that the way these men cope with their relational limitations is to frame them as a sign of superiority. They convince themselves, then their wives, that social intelligence is a disorder, and emotional matters are mundane.

Once I figured out that my client’s husbands were on the spectrum (which in many cases was confirmed by independent evaluation), I began to wonder what took me so long to figure it out. Why was I ready to believe that clear signs of high social and emotional intelligence were signs of dysfunction? My head was full of theories and symptom clusters and stereotypes. “Helicopter Moms,” “labile emotions,” “undifferentiated,” skewed my perception.

Affect is not pathological. Nor is being highly attuned. It is pathogenic to convince someone that having emotions is bad. Now when a client tells me her partner thinks she’s overbearing, I ask myself where the pathology actually lies.

Helping our clients who are married to people who are very high functioning on the spectrum means taking several steps. Helping them recognize and come to terms with their partners’ limitations is vital.

Helping them value their own social and emotional intelligence is essential. Of course, we, their therapists, must value these virtues if we are to help these clients to thrive.

“Janelle,” I lean forward. “The grad student who’s getting a research assistantship because of your fundraising does not think ten thousand dollars is trivial. Congratulations. Well done.”

* The people in this piece are not actual clients. They are composite characters.