The monthly DiS podcast

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Sunday, July 26, 2020, 17:05

This month's post is thinking about PCP and why it is useful for thinking about and as a therapeutic approach to use with young people (and adults) with autism.

PCP does not offer an explanation for why there are people with autism, although evolutionary theory might. It seems to make sense that society does need to be diverse to facilitate its survival. Without a with a range of skills and abilities, society would be less strong and have fewer possibilities.  The way that autism is defined is tautological - autism is what is defined as autism. I have seen it change in my lifetime, from a condition thought to apply only to very few people with additional learning disabilities, to one used to describe very many more. As society has become increasingly focussed on sociability, particularly in schools and at work, the number of people diagnosed has risen. Now we are at a point where the demand for assessment far exceeds the capacity, at least in the UK’s NHS.

Of course, any diagnosis is a construction, with society determining what it is. In PCP terms this is commonality, shared construing between people. Societies and organisations have decided what makes autism and agreed that it is a problem that needs noting. People with autism are grouped together by the diagnosis because they share core difficulties with social communication and adapting to situations and experiences. They are also more likely to have difficulties with sensory processing, although those problems are not exclusive to autism.

I have pretty much always had a PCP approach to thinking about autism and its core problems. This is probably because I came across them at a similar time in the early 1980s when I was a residential social worker in a school which nowadays would be full of people diagnosed with autism, ADHD or attachment disorder. The school used a combination of behavioural and psychotherapeutic approaches. On my first visit,  I met a William who spent the morning connecting and reconnecting wires to a battery to make a light light up. He did not get bored and immediately returned to the task when he was obliged to leave it. The place was noisy with boys playing and plenty of disagreements to watch but William did not look what they were up to. He smiled to himself as he enjoyed what he was doing. When I spoke to him, he was clearly not interested in chatting. I was so curious about William and how and why he would want to spend his morning doing that. I found out that he had a number of invisible animal companions that he did speak to but that he showed no interest in relating to his peers. I wanted to know about William’s internal world, why was he  different to most 11 year olds? I wondered what he thought about, what he wanted out of life and whether I would be able to make any kind of relationship with him. My knowledge was drawn from psychotherapy, psychiatry and education and none of their theories worked well to explain or to understand William. He drove some staff mad with his behaviour, largely because they treated him as if they had to draw him out of some sort of distressed aversion to people or as if he was being deliberately oppositional. I spent a lot of time with him and I did not see that in him - he was not afraid of the world nor of relationships. William just had different interests. He had views but they were not emotional as staff had thought - he was not trying to ‘get one over them’ but was trying to survive and do things he liked.

I worked with William in various roles through my five years at the school and we did develop a relationship in which we could share jokes, talk about things and spent time together doing things he enjoyed. Gradually, I persuaded him to try some new things and at 15 he read his first comic and loved the slap stick humour. William challenged every aspect of the school and residential system because his priorities were different and I loved that about him. He did not bow to social pressures he did what he saw as fair and reasonable. Once I understood his perspective better, I was able to help other staff to adjust their way of relating to William and he grew into a young man who was seen as funny and very direct. His sharp wit became appreciated by his peers and less staff attention was paid to trying to get him to stop doing things that caused no-one any harm. William had a profound effect on me. I learned that I had to persist and be creative if I wanted to help young people like him and that the most important thing was to find out how those young people made sense of the world and then help other people to understand them better.

Autism is a condition defined in relation to other people. To me, the core of what is defined as autism is about construing - it is about an orientation towards the world. It is the way a young person interprets their experiences - what they notice, what they pay particular attention to and the way they make sense of things. Often, those who are described by an autism diagnosis have a much greater interest in objects, patterns, movement and sensations than they have in people (a non-person orientation rather than a person orientation). From research, we know it applies to people with autism from the beginning of their life. Their construing of non-person experiences may be very sophisticated. They might notice tiny details and differences between creatures, objects or situations. They may be able to order them in terms of various characteristics, showing ability to hold that information in mind and manipulate it. They may notice tiny changes in sensations and track moving objects with skill. Their attention to detail is remarkable and it can be an asset, leading them into careers where these skills are highly valued. However, the focus of their attention and interests may be very intense so that the family of the person with autism finds it hard to cope with their preference for detail and repeating patterns.

The usual reason for a referral for an autism assessment is the young person has difficulty understanding and relating to people. Typically, they struggle to construe differences between people and within people, although they may have excellent observational and intellectual abilities when applied to non-person experiences. They have difficulties with social imagination, with putting themselves in another person’s shoes. Construing is central to all of this: the diagnosis itself is about construing.  If they were able to explain their repetitive behaviours and inflexibility in a way that made sense to (and was acceptable to) their parents and teachers, the young person might not be referred. Their difficulty construing other people and their constructions makes it difficult to explain and to seek help. The adults around them have difficulty construing the young person’s constructions, as I did with William.

Children with autism are likely to have fewer constructs about people, arising from their orientation towards non-person experiences. Constructs develop through experiences, through differentiating one experience from another. A difference has to be noted for a new construct to arise (e.g. to describe a paint colour as pale pink requires reference to constructs about pinkness, and to non-pink colours). In the same way, to describe a person as furious requires reference to constructs about anger - including verbal and non-verbal construing, and to the context. Context is crucial in construing people’s internal states because we use our construing of the context to anticipate the likely construing of the people in it. Think about fighting - it is usually associated with anger unless the people are in a setting such as a boxing ring or a judo tournament. We use our construing of sport to help us to construe the internal states of the people in the fight and we construe them as not angry.

Difficulties recognising what is real and what is pretence makes people with autism more vulnerable to grooming, scams and being ill-treated in their close relationships. People with autism usually have difficulty construing many things at the same time and people and contexts are extremely variable. I have come across a number of children with autism who do not understand that the apparent construing of wrestlers is an act - they are not angry and do not hurt each other but pretend to do so for the wresting show. Their internal state does not match their visible fury with another wrestler and the clues to that being pretence lie in a person’s ability to construe the setting (a wrestling ring, paying viewers, the build up to the match, the predictable characters, the impossibility of surviving some of the throws and holds without serious harm). The simple construct real rather than not real represents many constructs about the context, each context factor one has to be construed in order to reach the conclusion that wrestling is pretence.

The construing of emotions is related to experiences and in PCP terms, emotions are construing. People with autism may not be able to recognise a range of emotions, nor to show them clearly. It does not mean that people with autism do not have experiences that generate particular emotions, but that their experiences may not have been examined and considered sufficiently in order to define their emotions. They might be less differentiated or their social communication skills are a barrier to telling people about their emotional states. There are many teaching programmes designed to develop the construing of emotion by people with autism. There are also useful personal accounts of autistic people learning emotions as an intellectual exercise (Donna Williams’ account, Somebody Somewhere, is worth reading).

Young people with autism may not be able to predict the impact of explaining their construing on another person’s construing, not realising how it may be helpful to the other person in some way or  how it could affect the way they are construed by the other person. Typically, children with autism do not provide explanations of problems which include emotions, history and context. They may not realise that they are relevant or that it is worth explaining because it will change the outcome of the problem. They also may not have construed their experiences at a verbal level. For example, a child may notice the way a bully repeatedly glares at home and takes every opportunity to shove him in the corridor but the child is not able to provide a verbal explanation of those experiences. The teacher, therefore, might not be unable to understand why the child has immediately hit the bully so hard when he was tripped over by him in what seems to the teacher to to have been an accident. The explanation would require the child with autism to construe the constructions of the teacher,  the context, and the school disciplinary system and explain that construing. Their social communication difficulties make this too difficult and often they will not be able to explain something which puts themselves in a good light.

In 2001, Harry Procter published a really helpful model Personal Construct Psychology and Autism and I would recommend that you read it if you have interest in this area. It is quite a theoretical paper but a great summary.  You can download it from ResearchGate.

So what does PCP have to offer when working with people with autism? It takes each individual and tries to understand them, with a view to supporting their development. It does not criticise or define their difficulties in a way which puts them down. It would not view them as wrong in any way, but as trying to make sense of their experiences, just as we all do. When viewed through a PCP lens, people with autism are no less, or more, than everyone else and the way they ‘tick’ can be understood using a PCP framework, just as for people without a diagnosis.  Within PCP there is no notion of right and wrong, no positive and negative, separating construing from judgement.  Kelly encouraged us to be curious about people, to wonder how they make sense of the world and to ask them to tell us. A PCP therapist does not need to have a huge mountain of knowledge about autism to help a person with autism. They do need to know how to ask questions of individuals and how to help them to express their views. Of course, studying autism intellectually is interesting but I am conscious that the knowledge base is related to research findings and that research is funded according to the theories held by a much smaller sub-section of society. I wonder what research might be done if people with autism determined the direction of research in autism?

My experience (and research) suggests that people with autism do not typically have one problem or diagnosed condition. They also have a myriad of background factors, not least being their family situation and developmental experiences. An advantage of a PCP approach is that it doesn’t matter how many diagnoses a person has. They may have a number of additional conditions, all with a set of guidelines of best practice for assessment and intervention.  It is common for research studies to include people with single conditions and to exclude people with the murkiness of a number of diagnoses. This is a recognition of the difficulty of studying people. However, what should therapists do? Follow guidance for all the conditions, follow only some, pick and choose which to follow? A PCP approach to working with people cuts right through this. The focus is on the individual and what they make of their experiences. Their diagnoses do not determine the direction of therapy but they may inform the delivery of therapy.

PCP is an approach which is flexible. A therapist can use a range of techniques and there are none that must be used. If you want to learn more about using PCP approach with young people with autism, read the books and papers relevant to children. If you would like a free taster, there is a downloadable e-book on my website which has interesting examples of case work.

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