The Reality of Severe Autism (pt 2)

By Nathan E. Ory, M.A.

Coping with the reality of severe autism:
General concepts for supporting emotionally fragile individuals who display maladaptive patterns of adjustment. How are care providers to support a person who is not connected to others, who lives in-the-immediate moment, who reflects and magnifies other’s emotions, and who has little continuity of experience?

2. Creating stability after meltdown.
What not to do after meltdown?

The role of the supporting caregiver is not to attempt to “reason with” or “fix” the person. At the moment of high arousal, the role of the supporting caregiver is not to attempt to identify “the reasons why”.

One task for the supporting caregiver is to become aware that the individual who is “testing” his/her environment for safety will project their fearful feelings into their caregivers.

Thus, without understand why, caregivers might find themselves experiencing fear, arousal and anxiety.

In an attempt to self-validate their fear/expectation that the world is an unsafe place, some individuals may attempt to evoke threatening responses from their caregivers, which reinforce their “default” core belief that the world is an unpredictable, unreliable and threatening place to be. The task of the caregiver is to understand this phenomenon and to “finesse” the individual by not playing into this.

The task and role for the caregiver is to be a constant, reaffirming source to the individual, and to not get caught up in their drama of the moment.
What to do after meltdown?
A. “Correct” therapeutic goals, tasks, roles and attitudes:

The goal for the supporting caregiver is to try to cause the individual, who is experiencing disconnection and detachment, to feel momentarily connected and attached to their care provider.

The task and role of the supporting caregiver is to assist the individual to feel safe, secure, and bounded (responded to) by predictable, certain responses. Become their guiding light through the dense fog of their existence. Become their “compass point.”

The emotional attitude of the supporting caregiver is to try to cause the person who is “mirroring and magnifying” emotions to have a “smooth and calm surface” to reflect.

“They are exquisitely context sensitive. Whatever is going on right now is going to be reacted to.”

The caregiver’s demeanour should be one of “compassionate detachment” or “caring-lack of concern.” (That is, “lack of concern” about the outcome of your own caring response. Offer what you can but do not be affected if this is not accepted by the person.)

This detached emotional orientation may allow the caregiver to “deliver” a certain, calm, predictable response without becoming “caught up” in the individual’s personal emotional storm. Be like a warm, wood stove. Offer your emotional “heat”, but do not pursue the person trying to get them to consume your own “fuel.”
B. Trust and the front-line support worker: The concept of supporting the individual in a “mental health sanctuary.”

While encouraging effort towards supported problem resolution, a primary therapeutic role of caregivers is to attempt to support the individual’s self-acceptance and self-forgiveness. The role of caregivers is to attempt to “remove shame and self-blame.”

Once a person has had a meltdown (decompensated, fragmented and regressed) they will need to be carefully assisted to reconstruct a connection to their world and others in it. This will be necessary before they can “go back” to the way they were before they became overwhelmed. In their fragmented mental state, the individual’s ability to function becomes the responsibility of the care provider.

Caution: One role of the supporting caregiver is to understand that “your own feelings of frustration at your inability to help the individual may feel like anger and rejection to the individual.”

In-the-moment that you are looking at and talking to a person who is in a state of reflective agitation, you have to project that you really like the individual you are supporting. This feeling must be genuine.

This is the challenge for caregivers supporting such challenging individuals. It is hard to genuinely like the person who has just destroyed your things, hit you, or is blaming you and cursing at you.

Trust is established by empathizing with the individual, acknowledging their anger without retaliation, while at the same time reinforcing consistent boundaries.

The interaction between the individual and their therapist is the:

“foundation for trust, object constancy, and emotional intimacy. The therapist must become a trusted figure, a mirror to reflect a developing, consistent identity. Starting with this relationship, the individual learns to extend to others appropriate expectations and trust.” (Kreisman & Strauss, p. 125).

Licensed therapists have the training and the time to assume these roles. This is a much harder task for a care provider in a residential or work setting. For front line care providers the answer has to be much more rapid, systematic, and predictable.

The mechanics of beginning to build a sense of trust and connection and inner consistency is to build “rule oriented”, predictable and even ritualized interactions.

– Roles and boundaries need to be explicit and defined for all the players.
– Actions and transitions can be bridged with visual and concrete props.

When required to operate in the world outside of such predictable, constructed interactions the individual remains vulnerable. The long-term goal is that, eventually these “mediated and manufactured” interactions become a familiar and genuine basis for relationship.

For the caregiver on the front line, the immediate task and role is to be a “rock” the individual can stand on. Support the individual to be “successfully dependent” Do not pressure the individual to perform all of the time, what they may only be able to do when they are calm and secure. Provide the calm and secure environment that allows them to function.

When the individual you are supporting is in an extreme state, it may help a care provider to imagine that you are operating a “mental health sanctuary.” Assume the person is in a chronic state that they may linger in for a long period of time without getting “better”. In this mind-set, offer the individual support until they are internally stable enough to re-engage with the level of assistance that you are able to offer.

Nathan E. Ory, M.A.
Registered Psychologist
Nathan Ory is a psychologist with the Island Mental Health Support Team,
Victoria, B.C.

challengingbehavior@shaw.ca