We have all had to adapt the way we work to accommodate limitations and restrictions. It’s been quick, unpredictable, and more than a little stressful at times. However, in my line of work, I’m used to adapting and accommodating my practice to fit the needs of my students. I am an assistant psychologist in a specialist college for autistic people.
In light of the recent pandemic, I’ve gone from working directly with students and swapped it for my sofa and Zoom. But I have also been trying to make sure that these unexpected changes to how I give my support remain bespoke and accommodating for my students’ needs.
In the UK there are roughly 700,000 people who have been diagnosed with autism. Autism is described as a life-long disability with persistent difficulties in social interaction and communication, rigid or repetitive behaviours, and restricted interests. Autism is protected by the Equality Act (2010), which explains that reasonable adjustments must be made to allow the individual to receive the support they need, in whichever form that is best for them.
So, what reasonable adjustments would any therapist have to make to help an autistic person access therapy? I would like to focus on Cognitive Behavioural Therapy (CBT), which is considered the ‘gold standard’ of psychotherapy, and appears to be effective for many psychological disorders in a wide range of client groups. CBT is a short-term, goal-focused talking therapy. However, the difficulties present in autism can appear to be a barrier in CBT: the ability to understand and articulate concepts, the ability to engage in social interaction, deficits in theory of mind, and rigid thinking. However, when reasonable adjustments are made based on individual needs, it can be just as effective.
So based on my own experiences, a growing area of research, and NICE recommendations, here are some ways we can adapt CBT to accommodate for autism.
Be ‘autism aware’
One study suggests that 64% of therapists have not received specific training on autism, even though 90% have had experience working with an autistic person. But this doesn’t mean you can’t start educating yourself with resources online. Autism is a complex condition and presents differently in every individual. Once you are aware of the strengths, difficulties, and differences in autism, you are then able to understand why you’re making these adjustments, overcome barriers, increase engagement, and be better as a therapist overall.
Allow for longer processing time and shorter sessions
Embrace the silence! Some autistic people may have longer processing times than neurotypical people. Therefore, they might need more time to think about what they have been asked so they can find the best way to respond. If you find yourself unsure of whether the person has understood what you have said, ask and repeat what you have said.
If you re-phrase the question, it could potentially make it more confusing. When scheduling next sessions or thinking of the length or frequency of the sessions, make sure you allow for the processing time of the person. For example, I’ve had to give a week’s notice on any unavoidable changes to my therapeutic routine for one student, as they needed time to process and accept it and then to get ready for the next session.
Make use of interests and hobbies
Working with a known interest can be a motivator, a theme, and an engagement device. WWDWD (What Would Dr Who Do?) had become a go-to for me when I worked as a student who saw everything through the eyes of Dr Who. When reflecting on current issues, it was difficult for the student to understand and explain their own thoughts and feelings, so using their special interest in Dr Who made it easier for us both to indirectly approach this subject.
Make use of visual information
Visual aids can help provide something concrete for abstract concepts like emotions, thoughts, and feelings in ourselves and in others. In our therapy room, we have a whiteboard to draw things out on to explain as part of the psycho-educational process. I’ve also used cards to draw out cross-sectional formulations that students take pictures of.
Everyone has a sensory profile: sight, sound, smell, taste, touch, interception (what is going on in the body), and proprioception (awareness of the position and movement of the body). This is more noticeable in autism. People can be hyposensitive (need a lot of input through senses) or hypersensitive (easily overwhelmed by input). Some adaptions I use: lights that can be controlled by a dimmer switch, having a rocker chair, fiddle toys, and not wearing perfume.
The key thing is to ask people how you can make the environment better for them so they can relax and focus. Some of my students prefer to go for walks as the movement helps them process how they are feeling. It feels more indirect as we’re not actively looking at each other and the natural environment provides a therapeutic backdrop for us.
It can be particularly difficult for some people to learn skills in one setting (such as a therapy room) and then learn to apply them to a new setting (the real world). Issues with executive functioning (motivation, initiating, and implementing) can mean that setting homework can be overwhelming or forgotten because ‘this is what I do with Emily in therapy, not at home’.
This can be linked to black and white or rigid thinking that is common in autism. This is why in my setting, we are particularly lucky to have support staff on-site, who can encourage the development of CBT skills outside of the session. Key people (a parent, carer, or partner) may also be involved in the session if the person wishes.
I think as therapists, we should always be ready to adapt how we deliver our services. You never really know what differences or difficulties your service user may have. To be more open-minded about how we all interact with the world means that we can accommodate diversity in any form, should they need our help.
Emily Daniels is an assistant psychologist at The Cambian Group.