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PsychiatricApproach
Psychotherapeutic Nursing in the Treatment of Adolescents With Asperger’s Disorder
TOPIC: The conundrum of how to carry out psychotherapy Andrew Cashin, PhD, RN, MHN, NP, Dip App Sci,
with an adolescent whose primary currency of information BHSC, Gcert PTT, MN, is an Associate Professor, Justice
exchange is visual as opposed to linguistic, and who is Health Nursing, The University of Technology Sydney and
unable to develop a unified base of knowledge and hence NSW Justice Health, New South Wales, Australia.
generalize concepts, has confronted many mental health
nurses in their encounters with individuals with Asperger’s
disorder. At the currently estimated escalating rate of
Asperger’s disorder is one of the three diagnoses
that collectively make up what is currently considered
occurrence of 1 to every 100 individuals having an autism
to be the construct autism. Autism is a developmental
spectrum disorder, and the estimate that 80% of these people neuropsychiatric disorder characterized by marked
have average or above intelligence, it makes sense that difference in the processing and storage style of
Asperger’s disorder is frequently encountered by child and information as compared to that experienced by those
adolescent mental health nurses. Asperger’s disorder with typical development. The primary currency of
represents a different way of being in the world that is information exchange for a person with autism is
associated with a higher frequency of anxiety disorders and visual, as opposed to linguistic; and a unified base of
depression than experienced by neurotypical counterparts. knowledge about the world is not formed as part of
The inherent concretization in the externalization the developmental process. As the majority of people
techniques in narrative therapy provide a novelly successful in society do not have autism and can be considered
approach to psychotherapy with people with Asperger’s neurotypical, a serious mismatch occurs in mainstream
society between the ability of those with autism and the
disorder and in many cases resolution of the conundrum.
social demands placed upon them. As a consequence
PURPOSE: This paper considers the features of Asperger’s
of this mismatch, those with autism often experience
disorder and its consonance with the techniques of narrative
anxiety and depression to a pathological degree as
therapy, and utilizes a case example that shows the potential part of the tensions of living. This emerges at transition
efficacy of the application of this established approach in a periods and is often most intense as the person is
new context. engulfed in adolescence. A problem arises in working
SOURCES: Contemporary literature on autism and with a person with autism on these tensions of living
narrative therapy. when the tools we commonly use in psychotherapy
CONCLUSIONS: The implication of the potential are largely designed by, and for those with, typical
application of narrative therapy in psychotherapy with development. How do you use words to ease tension
individuals with autism is raised. with someone who is not a linguistic processor of
Search terms: Autism, autistic disorder, Asperger’s information? Strangely enough, the answer may be
disorder, narrative therapy found in a therapy designed to work on the stories
individuals tell themselves about the world and their
place in it. Although grounded firmly in the realm of
linguistics, narrative therapy’s focus on the here and now,
and externalization techniques, are useful in the work
with people with autism. Although instead of editing
of stories the task is largely coconstruction of the story
with the individual, the outcome can be dramatic as
Journal of Child and Adolescent Psychiatric Nursing, Volume 21, the person finds a scaffold to negotiate specific crisis-
Number 1, pp. 48–56 laden occurrences.
than someone who has autism and an average or it has come to be realized that the impairment of
above average IQ. Yet it is not the autism we are com- autism contributes to high degrees of anxiety for the
menting on, but rather the overall adaptive behavior person in social environments, such as that charac-
or functioning. Our current diagnostic practices terized by school and exacerbated by the complex
represent a radical shift in the balance between people social demands of adolescence. This means the person is
diagnosed with an associated or comorbid intellectual often reacting to stress and experiences more tension, thus
delay and those with average intelligence. The trend exhibiting more of the extreme end of the behavioral
has now reversed from 10 years ago and the majority repertoire than a more relaxed person.
of people diagnosed now have only mild intellectual To understand the nature of this tension, a very
delay if any (Autism Association of NSW, 2001). Such brief foray into the presumed thinking and learning
individuals with the requisite triad of impairment and style inherent in a diagnosis of autism, and how this
no intellectual delay are often said to have Asperger’s differs to the typical style, is fruitful. The triad of
disorder. impairment is the behavioral or outward representa-
tion of a presumed style of receiving, processing, and
storing information (Cashin, 2005). To borrow a term
that has been assimilated into the autism vernacular,
this way of handling information is different from the
Autism itself does not affect personality, or typical way, it is not neurotypical (Gray & Attwood,
1999).
what some prefer to call temperament. Just For most people the primary mode of dealing with
information is verbal. Thoughts are initially experienced
like all people, people with autism range as images but are not processed until words are
attached. The linguistic code is not necessarily words
form passive to active, from quiet to loud, as we would recognize them, but more a type of
mentalese, which is “the language of thought in which
from “internalizes” to “externalizes” or our conceptual knowledge is couched” (Pinker, 1997,
p. 90). Thoughts are stored in each individual’s own
whatever way you wish to say it. personally constructed filing cabinet in a gestalt,
engram, or personal draw based on language. The
cabinet is arranged on the basis of like and similar ideas,
grouped into concepts. The great gifts of abstraction,
Autism itself does not affect personality, or what some fist described by Aristotle, allows people to seek
prefer to call temperament. Just like all people, people things out and work out what is like or similar, hence
with autism range from passive to active, from quiet to where to store and retrieve information (Gadamer,
loud, from “internalizes” to “externalizes” or what- 1966/1976). Through the power of abstraction the
ever way you wish to say it. Like all people, tempera- individual is able to store experiences in an orderly
ment can affect success at social integration, especially fashion, as each experience is stored next to, and builds
when mixed with a comprehension deficit. A confused upon, knowledge in similar or related areas. Through
and anxious passive person in many social situations the development of a unified base of knowledge the
is accommodated more than a confused and anxious person soon has a repertoire of similar or like behaviors.
active person based on the element of disruptive- When confronted with a situation the person can reach
ness. Although autism does not affect temperament, into their filing cabinet and search for a clue of where
the world to promote social adaptation while working to each individual personal in-head filing cabinet
on specific problems of living. These complex stories where information is stored and processed based on
include those related to who they are as a person and the individual’s personally constructed meaning.
their interpretation of events that signal to them where Although epistemologically incongruent with what
they fit into the world. It is very much about re-ordering would be expected to be of use in work with someone
parts, or in some cases the whole of the personal in with autism, the tools used in narrative therapy
head filing cabinet. This occurs around specific and provide the platform for a novelly successful and
concrete incidents. changing approach to psychotherapy with such less
typical thinkers.
It must be acknowledged that the use of social
stories in working with those with autism is common-
place. Carol Grey (2000) developed an approach where
Although epistemologically incongruent an individual with autism is given a whole chunk of
information about a social event. This chunk includes
with what would be expected to be of use in information about the context in which the particular
story is applicable, clear ideas or rules on what to
work with someone with autism, the tools do, and information how the person’s behavior will
impact upon others. This is in keeping with the chunk
used in narrative therapy provide the style learning of those with autism and compensated
for the theory of mind deficit by inclusion of informa-
platform for a novelly successful and tion on the perspective of others (Gray). Further,
these stories are often augmented visually to deal
changing approach to psychotherapy with up information in the currency of relative strength.
The stories are designed to provide concrete instruc-
such less typical thinkers. tion on how to navigate a social encounter. However,
how to move beyond giving someone a story and
engaging adolescents as coauthors has not been
addressed. This is an important issue as it is believed
As acknowledged, this is a form of therapy that is coauthorship will improve meaningfulness, ownership,
linguistically based and that evolved from the early and hence utility of the story (Waites & Swinbourne,
creative work of Michael White and David Epston 2001). Social stories are not in themselves a form of
(1995), who made accessible what are essentially narrative therapy. In using social stories there is no
complex concepts based on existential psychotherapy. presumption of working on individually constructed
This is a therapy primarily created to use with neuro- meanings. A deficit in the development of knowledge
typical individuals. A foundation element is the notion related to use of social stories is that of the question of
of individual construction of meaning (Epston & how to engage those with autism in the cocreation of
White). The notion is embedded that each individual stories.
linguistically codes information and constructs meaning The tools employed in narrative therapy offer the
through the grouping of like ideas into concepts or means to engage adolescents who present with the
engrams (Ogden & Richards, 1952). A degree of abstrac- repetitively problem-saturated situation of not having
tion ability is presumed. The concepts when grouped a clue. These tools can be applied in an epistemologically
form the unified base of meaning or knowledge likened congruent way to the information processing style of
Asperger’s disorder at the age of eight. He arrived at was very sorry that he did. Justin labeled his intense
this point after previous diagnoses of first, attention anger as “the bang.” Justin was asked to describe “the
deficit disorder at age four, followed by oppositional bang” and he gave a good description of what many
defiant disorder at age six. Justin was in the second would call an intense tantrum. Once in full swing
term of year seven at the time of referral and was Justin felt unable to change his “bang” behavior. Justin
described by his mother as “not coping with school.” agreed to spy on “the bang” so we could learn how it
Justin had recently been suspended for 1 week after behaved and worked. He agreed to keep a diary (spy
an incident in which he had verbally abused and sheets) that we could look into at the next session
physically pushed a teacher in his math class. planned to be in 2 weeks. In addition to this he
Justin is now back in school. While Justin freely agreed that we should draft a letter to the school
acknowledged that the incident had occurred he had counselor to let her know of our plan so that she
been unable to explain why, or actively participate in could tell his teachers and if they spied “the bang”
any planning on how to prevent recurrence. The before Justin did, they could alert him to its presence.
school counselor had attempted to develop a graded Justin’s mother agreed to share the strategy with
strategy plan that was tied to escalating anger, but other family members.
became frustrated when Justin could not be engaged
in the process. Justin arrived in my room in the medical
center accompanied by his mother.
Upon arrival Justin’s mother described what had
led to the decision to see me, and her intense sense of
He agreed to keep a diary (spy sheets) that
hopelessness in her ability to help Justin survive
schooling. She described ongoing incidents at school,
we could look into at the next session
and before this in preschool where she constantly felt
the need to defend Justin but was at the same time
planned to be in 2 weeks. In addition to this
unable to understand why he behaved as he did. Justin
sat quietly looking out of the window but verbally
he agreed that we should draft a letter to the
participated in the session if a question was directed at
him. Both agreed to allow me to get to know Justin
school counselor to let her know of our plan
away from the problem. What emerged was a
description of a boy with a quirky sense of humor that
so that she could tell his teachers and if they
enjoyed his computer and PlayStation games. A boy
that loved animals because they were simple, but who
spied “the bang” before Justin did, they
was very confused about people. Justin said he often
felt that he did not belong, particularly at school.
could alert him to its presence.
Justin was able to describe the concrete incident
that led to his suspension but could give no account
for his behavior. It became clear that Justin’s anger
had crept up on him and that he was as surprised and Justin returned after 2 weeks with his sheets. “The
as scared by the explosion as his teacher. It became bang” had occurred three times at school and once at
clear that Justin did not label his feelings and that home. We looked for common elements and signs that
intense feelings just seemed to arrive with no warning. “the bang” was coming. Justin realized that it did not
Justin said that he had no intent to hurt anyone and creep up as quickly as he thought. He identified that it
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