Transcript Understanding and Helping Families

Understanding and Helping
Families
A UNDERSTANDING
OF “THE SPECTRUM”
AND THE CLINICAL
IMPLICATIONS FOR
THE FAMILY
Limited Family Therapy
 What has kept family therapy from
being a common intervention with
families on the spectrum?
Should Be A Perfect Match
 But few researchers, clinicians and
theoreticians have established a recognized
field
 Obvious pockets of care, but not widely
available
But, what else is at play?
 Possible power versus possible
powerlessness
 What is the impact of parental interaction
on behavior?
Political Issue
 How to discuss this question without raising
guilt?
 Understanding how family interaction can
be improved must have certain advantages,
even if “the patient” does not appreciably
change.
Therapist must believe…
 The neurological difference may or may not
be susceptible to change based on family
change.
 True systems thinking removes blame.
Holding Values
 Slife, 2007
 One does hold values, it is the abuse of values which
is a problem.
 If one loves someone on the spectrum (parent,
sibling, extended family, close friend, wonderful
client, student…) they will hold a value that reflects a
view.
Gurman and Kirshen, 1981
 Is It Effective? YES
 MFT is efficacious and FT is often more effective or
as effective an individual when the problem is
attributed to a family conflict.
 Both behavioral and non-behavioral were superior
(2/3) to no treatment
Mechanisms of Change in FT
Multiple perspectives on the problem
2. Members were able to shift blame from
one individual
3. Impasse Resolution-cases whereby the
family moves from the problem state
(arguing over behavior) to resolution (focus
shifts to relational nature of problem)
1.
Mechanisms of Change (cont.)
 4. Therapeutic Alliance-basically a position of
collaboration
 5. Reduction of Within-Session Negativity (more
reframing and balance). This would further result in
more verbal discussions and less defensiveness.
 6. Improved interactions and behavioral
competency.
Research on This Exact Population.
Virtually non-existent
Minor, but Intrusive Problem
 One’s embarrassed, one’s is public and an advocate
 The couple asks you, “what do we do when he is
unwilling to go out to a restaurant, and I want us to
still do fun things?”
Let Us Now Turn to the Family
 What is happening to them at that moment they
officially hear the diagnosis?
Standard Responses to Diagnosis
 1. Profound sadness
 2. Anger
 3. Defeated
 4. Over-drive
Language
 Person with autism
 Person on the spectrum
 Autistic person
 In my view, all equal
Lost and gained
 Each family, and each member of a family must
understand that which was lost and that which was
gained with the birth of a autistic family member.
 Each person with autism is strikingly different, thus,
no one can predict what particular factor is most or
least difficult to accept.
Reponses
 Hear them
 The continued healing effect of empathy
 The challenge of remaining empathic to people who hold
different positions
 The process is not identical for different people
 Don’t be so quick with intervention because it may
appear dismissive
The Family with Autism
 While their child may meet diagnostic criteria they
are likely to be looking for another perspective and a
“reality check.”
 Will you take my son’s (daughter’s) concern
seriously, and provide him (her) some comfort?
Three Theoretical Foci of Family Therapy
 All are systemic
 Problem-Focus
 The problem that brings them in
 Interactional
 Patterns of interaction that create tension
 Intergenerational
 “Bruises” caused by some past relationship, trauma or deficit
Possible Sequence
 Couple
 Individual on the spectrum
 Sibling
 Family
 Possible extended family
In my opinion, begin with the couple.
 Getting to know them
 Getting a very clear sense of the family, with special
attention to getting a complete understanding as to
the personality and style of the child or young adult
with autism.
 Providing some education, if requested and the
therapist knows the literature or multiple anecdotal
cases in that area.
Autism is a Spectrum
 This we know, but what does that really mean?
 Each kid has:
 Particular Mood
 Sensory
 Specific social relatedness
 Anxiety
 Some repetition compulsion
 Communication (the area we can best address in order
to serve all the others)
One brief screening devise is used with the couple
 Three primary purposes

Assist therapist in being able to best connect with young
person

Assess, very casually, if the view of this family member
generates disagreement or mutual support

This can assist in producing goals and a clinical direction
for the work with the family.
Autism Trait Screening
 Addresses six primary areas.
 Social Skills
 OCD or Repetitive Thoughts
 Academic/Work Skills
 Communication
 Outbursts/Emotional Regulation
 Level of Independence/Dependence
 Has three additional questions that provide
important clinical information
Follow-up Questions
 How publically visible is the disorder for your child?
 What is the degree to which the symptom interferes
with daily life?
 Are there other psychological conditions that merit
attention?
 Please describe the actual behavior or thought noted
in the “Repetitive & Rigid Scale.”
 If there are volatile incidents, do they ever become
physical?
Matching possible parental reactions to positions on
the graph
 This is not to label, but to
normalize
 Differences in opinion are
important, especially between
family members
OCD/Repititions
 The more public the more the question is asked:
 “Do I need to inform this person about my child’s special
needs.”
 “How do I react when a child innocently mentions it.”
It
helps to prepare (actual answer &
feelings)
Social
 “Do I encourage friendship with kids who are more
typical?”
 “Do we engage social skills group?”
 “How much do I explain to my child about their style
and the effect of that style?”
Academic
 “Why don’t school personnel find a way to tap this
extraordinary skill (even if the skill is remembering
tons of dialogue from Disney)?”
 “Why can’t they understand his (her) behavior
instead of only reacting to behavior.”
 “Why, on the occasion when they do look beyond the
behavior is there idea always regarding medication?”
Communication
 “How much do I interpret?”
 “How much, literally what percentage o his (her)
verbalization is gibberish?”
 “How often to assist others in communicating with
him or her?”
 “Is there some humor tucked inside there?”
Regulation/Outbursts
 Very tricky
 A real question of walking the balance of learning
more or hoping for a natural calming.
 Safety
 Ross Greene, Ph.D. “The Explosive Child”
Level of Life Skill
 “How do I know when to push, and when to accept?”
 “Since we used books in the past that had
developmental milestones to look for, how do we
adjust?”
 “How do we agree on ‘level of independence’ when
we have such different level of fear?”
 What is one skill that would be really helpful in the
family?
The Session with the Parents
 Listen
 Comfort
 Educate
 About autism
 About systems
 Prioritize
 Reframe
 By understanding personal reactions
 Create new paradigms by using sub-systems
The next session is often with the autistic family
member
 The first and foremost priority is to be fully aware of
all the points the young person is making. If you are
confused, carefully request clarifying details.
 Assess any workable problems
 Get permission to discuss together with parents
 Affirmation , Assignments or Summary
Siblings
 Research suggests generally positive findings
 Support groups for siblings are common until about
age 13
 Possible split session or separate session for the
sibling
Next session may be with whole family
 Not an absolute, but if possible and there is no
strong reason to leave out members.
 A clarity of issues and open family discussion about
dealing with certain concerns.
 Even problems that seem peculiar, should be calmly
understood and able to benefit from clinical
interventions.
Caveat
 Due to some of the characteristics of the autistic
member, if a meeting will simply create heightened
anxiety, then the session includes only the young
adult with autism and his (her) parent(s).
 Expressed anxiety is to be avoided, unlike in
traditional family therapy.
Two Cases
The Johnson Family
The Miller Family
 Outbursts in school
 Parental disagreement
 Difficult to break routine
 Different agenda
 Some outbursts at home
 Non verbal, some
 Solid couple, reasonably
supportive extended
family
 Sibling tension-within
normal range
outbursts
 Typical job issues
(parent)
 Very different extended
family reactions
Johnson Family
x
Jill
Jeffery
1993
1997
18
14
Autism
Thomas
Rebecca
Therapy
 Session with parents confirmed the parents were a
nervous, but very committed team. They wanted the
best for their “sensitive kid,” but they were unsure
how to trust or deal with the school.
 Session with Thomas and his parents emphasized
efforts toward tantrum control, group therapy, and
parental clarity.
 Session with parents and Rebecca to confirm an
understanding of her issues.
Miller Family
Bet
h
David
1991
1994
17
20
Sam
–In College
Joshua
–Lives in a residential setting
–No verbal skills
–Goes home for weekends
Therapy
 Sessions with parents first clarified the concern,
determined a desire to stay married, agreed to
slightly different parenting patterns.
 Session with whole family. Thomas brought his
“talker” and questions included him. He does like
his brother’s visits (a clear statement in session).
 Stress reduction
How is your role different?
 More of a consultant
 You are still doing therapy, but their needs are often unique
 Critical importance of being a “concerned contact.”
 Feel close caring people—fully understanding
 Advocate
 Look for self-cutoff which might be unnecessary
What is consistent with standard family therapy?
 IP may not be the primary issue or problem
 Systemic patterns are still very relevant
 Clarify communication and open channels where




possible
Increase empathic feeling throughout family
Support and affirm
Normalize, when appropriate and accurate
Reframing, when honest and appropriate, can be
extremely useful
Example of Common Reframe
 Parent is working on not being angry with the child.
 “Dusty is teaching you the value of patience. You
know that if you blow-up, even slightly, you will be
discussing it for a month. It may not be the way you
intended to learn how to become calm, but you are
learning how to be much more calm.”
 A good reframe is always true.
Family Therapy: Adding to a Spectrum of
Options
 If sometimes your family life feels like “Theatre of
the Absurd,” it is nice to have a non-judgmental
person who can laugh with you, not at you, nor feel
overwhelmed by pity.
 Family therapy provides a welcoming environment
where the goal is to understand everyone, clarify the
challenge, and provide multifaceted interventions.
Thank You.
 Questions?
 Scott Browning, Ph.D.
 Professor
 Department of Psychology
 Chestnut Hill College
 [email protected]
Diagnostic Criteria for Autistic Disorder
According to DSM IV-TR
A.
B.
C.
A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
1.
qualitative impairment in social interaction, as manifested by at least two of the following:
a)
marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures,
and gestures to regulate social interaction
b)
failure to develop peer relationships appropriate to developmental level
c)
a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing,
bringing, or pointing out objects of interest)
d)
lack of social or emotional reciprocity
2.
qualitative impairments in communication as manifested by at least one of the following:
a)
delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through
alternative modes of communication such as gesture or mime)
b)
in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
c)
stereotyped and repetitive use of language or idiosyncratic language
d)
lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
3.
restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
a)
encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in
intensity or focus
b)
apparently inflexible adherence to specific, nonfunctional routines or rituals
c)
stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
d)
persistent preoccupation with parts of objects
Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as
used in social communication, or (3) symbolic or imaginative play.
The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.
Diagnostic Criteria for Asperger’s
Disorder According to DSM IV-TR
A.
1.
2.
3.
4.
B.
1.
2.
3.
4.
C.
D.
E.
F.
Qualitative impairment in social interaction, as manifested by at least two of the following:
marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial
expression, body postures, and gestures to regulate social interaction
failure to develop peer relationships appropriate to developmental level
a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
(e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
lack of social or emotional reciprocity
Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at
least one of the following:
encompassing preoccupation with one or more stereotyped and restricted patterns of interest that
is abnormal either in intensity or focus
apparently inflexible adherence to specific, nonfunctional routines or rituals
stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or
complex whole-body movements)
persistent preoccupation with parts of objects
The disturbance causes clinically significant impairment in social, occupational, or other important
areas of functioning.
There is no clinically significant general delay in language (e.g., single words used by age 2 years,
communicative phrases used by age 3 years).
There is no clinically significant delay in cognitive development or in the development of ageappropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the
environment in childhood.
Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
Proposed DSM-V: ASD
 Persistent deficits in social communication and
social interaction across contexts



Reciprocity
Poorly integrated verbal and non-verbal, understanding, lack
of expressions, gestures and abnormal body language
Deficits in maintaining relationships
 Restrictive, repetitive patterns of behavior, interests,
and activities



Stereotyped, repetitive motor and speech
Excessive adherence to routines, or inability to change
Unusual interest, or reaction in sensory aspects of the
environment
Proposed Level 1 (Higher Functioning)
 Without supports in place, deficits in social
communication cause noticeable impairments.
 Has difficulty initiating social interactions.
 Clear examples of atypical responses to social
overtures.
 RRB’s cause significant interference with
functioning.
 Resists attempts to be redirected from fixated
interest.
Pro
 The diagnosis is now too broad; a more specific,
spectrum-based description.
 The more you fully understand the spectrum, the
better you understand autism.
Con
 It may remove services due to the change in
diagnostic category.
 Many people’s identity is now connected to the word.