Autism, and What Psychotherapy Can't Do

In the 1940s, Leo Kanner, the psychiatrist who first coined the term 'autism' postulated the cause as cold, intellectual mothers, nicknamed 'Refrigerator Mothers". This idea was then further developed into the 1970s by Chicago professor Bruno Betelheim who perceived autism as a psychological disorder in children, caused by mothers he compared to Nazi camp guards (as a child, Betelheim had spent time in a concentration camp and compared such children to camp survivors).

These days, it is accepted that autism is a neurobiological, lifelong, developmental disorder, with almost certainly originates before birth. Autism is how our brains are wired; it is not just a difference in our psychology, it is not a psychiatric disorder, it is not an emotional disorder and it is not caused by cold parenting or subconsciously hostile mothers.

Well, I say it is accepted... there are some hold outs in the world of counselling and psychotherapy.

Only the other day, I came across a psychotherapist talking about the 'controversy around autism', by which they didn't mean the controversy over how badly treated autistic people are, or how far we need to go to get total acceptance, they meant the 'controversy' over whether High Functioning Autism existed as a disability at all! The myth of autism as a mental illness persists.

I have yet to find a psychotherapist or counsellor who will admit to this directly, however. Maybe they are worried I’ll ask them for evidence of their theories (there isn’t any) or maybe they don’t even realise this is what they’re thinking? On the other hand:

• *A trainee asked me "Yes, but surely, with therapy your autism should improve, shouldn't it?"
• A fully qualified psychotherapist said to me "I'd be interested to know why you cling to this concept of yourself as autistic?".
•  I was contacted by another, offering to introduce me to someone who had 'recovered' from their autism.
• And most common of all, people who have self-diagnosed themselves with autism (usually shy, introverts who resemble the stereotype) and later declared themselves cured! (Such people rarely accept an extrovert like me as autistic).

Not Fitting the Stereotype

I don’t fit their stereotypes: I’m not introverted, I like people, I enjoy socialising. I often wonder how confident I’d be in my diagnosis had I not been diagnosed by a world-renowned neuropsychology professor who said I was absolutely typical for high functioning autism.

So, what am I doing that leads people to doubt my mental health? Some of my neurotypical friends suggested the following:

1. My body language, tendency to talk a bit too fast and a bit too loud, and my obvious effort to ‘track’ large groups (hard work!) can be mistaken for anxiety by people who don't know me.
2. Tendency to be extremely open and honest about how I'm thinking, and feeling can be somewhat startling to people, who may experience false empathy. For example, I say, “I’m worried…” and they think “Wow, I wouldn’t say that unless I was really, really worried” [Note: neurotypicals often feel it it polite to under-state their feelings and only mention them if seriously pressing.] But unlike neurotypicals, I am not understating, I’m saying it how it is. And I’m probably only saying it now because you asked me how I was feeling! (see ’Can I be honest with you?’ below).
3. I can be muddled and disorganised. It's called ‘executive dysfunction’ and is a little-known feature of autism (also found in dyslexics). It is part of the way my brain works, but since neurotypicals can get like this when stressed, it adds to the assumption is I’m seriously stressed! But no, I’ve just lost my pen and am distracted by looking for it, that’s all. No biggie.

So false empathy may lead people to mistake a mentally healthy autistic from a mentally unwell neurotypical. But that false empathy is underpinned by the myths peddled by Kanner and Bettelheim, who offered psychotherapy as a cure for autism.

In their day, the psychotherapy was offered to the mothers (I shudder to think of the harm that did); these days, the autistic person themselves may be offered psychotherapy for their ‘mother issues’. But in neither case did it change one jot of the person’s autism, it just increases the social pressure on the autistic person to ‘perform’ neurotypically, if they can.

Finally, as a lesbian woman I am struck by the similarities between this and this dismal history of psychotherapy and homosexuality. To this day, there are so-called ‘therapists’ who claim to be able to ‘cure’ homosexuality. It destroys lives and leads to incredibly low self-esteem, depression and anxiety. And for all that, it doesn’t even work! All it does is encourage a person to hide their true self.

This is why all of the major mental health professional bodies – the British Psychological Society, the Royal College of Psychiatrists, the BACP, the NCS, the UKCP... have signed agreements, such as the Memorandum of Understanding published by the BACP, banning so called ‘Conversion Therapy’ being offered by their members.

Counselling LGBTQ+ people should be about helping them become comfortable with who they are, not trying to change them. Likewise, counselling autistic people should be able helping them be a ‘fully functioning autistic person’, not trying to change them into neurotypicals (firstly, that would fail, and secondly, in failing it signals to the autistic person that who they fundamentally are, is flawed, broken).

Maybe we need a Memorandum of Understanding for autistic people?

Of course, there is not an exact equivalence between sex and gender diversities and being autistic. Many autistic people may have behaviours they wish to change, which are causing them difficulties - behavioural therapies, applied sensitively and respectfully may be useful interventions.

And autistic people are more prone to all sorts of mental health conditions than the general population – growing up autistic is a neuro-conforming society is a strongly ‘adverse event’ But it is essential counsellors and therapists know what is possible, and what is desirable to achieve – and don’t fall into the trap of colluding with those who demand autistic people conform, no matter what the cost.

I can’t tell you how many times I’ve known autistic people to present for therapy to ‘fix’ themselves after they’ve been bullied. The wrong people are in the therapy room!

As for me, I have had years of being told to go into therapy because clearly, I had mental health problems. No sane person could be like me! So I went into therapy, and a couple of years later, I’ve realised I’m mentally very resilient and I’ve finally started to question the assumptions that better = neurotypical.

I am embracing my autism. Which wasn’t exactly the result my naysayers expected.

Can I be Honest With You? Autistic v. Neurotypical Honesty

 One of the first things you learn in counselling training is the necessity of 'congruence', which roughly translated is about being honest and being your true, authentic self in front of clients - not putting on a front.

So from the start, honesty and openness is promoted as 'the way' to be a counsellor. Which gets confusing when, as an autistic person, you discover that 'honesty' isn't quite what you'd imagine it to be. In fact, to me, if feels as if neurotypicals rarely say what they mean. Thus, even a statement like "Be honest" has to be filtered through my experience of what people actually mean, rather than what the words seem to mean.

For example, a tutor may ask me to say what I think about the course. This is a potential trap - what if I said everything I actually think, including the things which I know are probably unfair, just passing thoughts, or a faulty impression.? I wouldn't want to be unfair or unkind! But if I only say the good stuff, that won't come across as truthful (and probably isn't entirely). So clearly some negative statements are expected. It is hard to steer an appropriate course.

The irony, of course, is that few neurotypicals are aware of their 'lack of honesty' - it is second nature, mostly unconscious and invariably done for the best of motives.

Being that 'honest' is contrary to other counsellor values about mutual respect, empathy, unconditional positive regard etc. But it is confusing for an autistic person to work out how 'honest' is honesty?

I recently met a very experienced counsellor who had come a cropper with an autistic client on the issue of honesty. The story I relay is a dramatization of the actual conversation. I've had to take a few liberties to disguise identities and also because unlike this counsellor, I am not experienced (so any errors are probably mine). This counsellor is mostly person-centred, using a few other techniques eclectically.

His client arrived and sat down. They exchanged the usual pleasantries and basic 'contract' (all the stuff about fees, cancellation policy, confidentiality etc) and then the counsellor said, "What would you like to talk about today?"

The client frowned. "I don't know. What am I supposed to talk about?"

The counsellor, putting his best Person-Centred hat on said "Well it's up to you. You can talk about anything you want to talk about."

So, the client said "OK".

The counsellor sat back, expecting to hear about the client's 'presenting issue'. Instead, the client launched into a detailed critique of Netflix Star Trek versus the original TV series.

He tried to waylay the client subtly. "I was hoping you'd talk a little more about how you are feeling..." he said.

"This is about my feelings!" the client exclaimed. "I'm feeling upset about what Netflix have done to Star Trek!"

"OK, so you're upset?" the counsellor reflected. He admitted to me he had been hoping that the client was using Star Trek as some kind of metaphor or symbol for his emotional issues. The client, however, hadn't read the memo.

"I'm upset about..." he began, listing in detail (as only an autistic person can do detail) his grievances with the new show's writers. Realising half an hour had gone by and he'd so far only learnt about Star Trek, the counsellor tried to explain how counselling was 'supposed' to work, in a very person-centred way.

He added, by way of explanation, "You see, I don't know much about Star Trek..."

Which was fatal, as the client then felt he had a duty to educate the counsellor about Star Trek lore (this is what talkative autistics like me do if someone says they don't know something - fix the 'problem' of them not knowing).

By this point, the session was so far off beam from client or counsellor's typical expectations that the counsellor was forced to jump out of his client-lead, Person-Centred model and actively interrupt the client.

"I think we need to go back a few steps and talk about what your expectations are for counselling, and what I can offer you," he said. And then he had to explain his methodology, in more detail than he generally had to do for his students, let alone a client.

The client asked a lot of questions about his approach, the pitfalls, the counsellor's expectations and clarified "So when you said I could talk about anything, you didn't actually mean that?"

The counsellor was forced to admit, he really didn't. "So, what should I talk about?" said the client.

Picking at random from the original referral form, the counsellor asked the client about his anxiety issues. "Ah well they got worse after an incident at work. Would you like me to tell you about it?" said the client.

"Yes," said the counsellor, "I think that would be a great place to start".

***

I share this story because it perfectly illustrates how neurotypical 'honesty' is framed by expectations and limits that autistic people cannot take for granted. Low support need people like myself do not have low support needs because we don't think this way. We are not neurotypical. We have low support needs because we're learned to 'translate' what is said, into what is meant.

So, when I'm in college and they say "Be honest. Say what you really think", please don't blame me if I think "No way".

Because "what I really think" is probably ephemeral, or irrelevant, or inappropriate, or the verbal equivalent of an intrusive thought. The world is not generally ready for autistic levels of honesty.

So, can I be honest? If you say yes, don't be surprised if you get it with both guns blazing.