Category Archives: Autism and Mental Health

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION: When Feelings Are Too Big

March 10, 2023Autism and Mental Health#actuallyautistic, #AutisticMentalHealthTherapy, #Neurodiversityadmin

This series of blogs and the release dates are as follows:

AUTISTIC SOLUTIONS RELATED TO TAKING IN INFORMATION
Part One: Using Words to Make Pictures (January 13, 2023)
Part Two: Using Words to Describe Pictures (February 10, 2023)
Part Three: When Feelings Are Too Big (March 10, 2023)
Part Four: Examples Using Paint Chip Visual Supports (April 7, 2023)
Part Five: Direct Instruction of Social Information (May 5, 2023)

Just like the sensory system information can come in too big for an autistic and then become difficult to manage, so to can emotional feelings get too big too fast, making them difficult to manage. Typically, in a therapy setting neuromajority individuals learn to identify and label their feelings. This knowledge then allows them a way to talk about their feelings and ultimately come to manage them over time.

When this approach is used with autistic clients it too often doesn’t go anywhere. Autistics tend to have difficulty when it comes to labeling feelings and are often left trying to guess the right answer. Additionally, while some autistics may find it helpful to talk about their feelings, it has been my experience that most talk about what another person said or did rather than their resulting feelings about the occurrence.

These concrete happenings are easy to know and repeat and are typically what carries the story line for autistics. Many times the feelings experienced by the autistic telling the literal and concrete aspects of the story are apparent to the listener by observing body language, but may not be apparent to the autistic.

Once the literal and concrete details of the story are in order, trying to understand the social ramifications of how another person acted is typically the next topic of conversation. Finally, once the story is sorted out logically and the understanding of the hidden social information is had, autistics might become aware of their own feelings and if so may want to talk about them. It has been my experience that autistics in therapy usually find it much easier to talk about their behavioral response to something another person said or did rather than their feelings around it.

There is no right or wrong way to talk about your own life stories. I merely outline this to show there are neurologically based differences in the way neuromajority and autistic people tell their stories.

Given all of this, I have learned that it is more helpful for most of my autistic clients, regardless of age, to learn about the size of their feelings rather than to struggle over labeling them. Since the purpose of labeling is to be able to talk about and manage feelings, we can cut to the chase of learning to manage feelings by teaching size of feelings.

The beauty of this is that It does not matter if the too big disregulating feeling is a positive feeling such as excitement over an upcoming event or a negative feeling such as sadness over cancellation of a favorite activity in that the too big feeling is managed in the same way regardless of the what the feeling might be. Therefore, no assigning of feeling labels are necessary to learn how to manage feelings that are too big. Often, it is more important that a client learn to manage/regulate too-big feelings in a short time rather than spending months (often years) getting stuck on labeling the names of these too-big feelings!

Selection from: Autistically Thriving: Reading Comprehension,
ConversationalEngagement, and Living a Self-Determined Life
Based on Autistic Neurology, pg. 141-142.

(The next blog in this series, Examples Using Paint Chip Visual Supports, details clinical examples of a variety of uses of paint chips as visual supports for showing size of feelings.)

Note: The author is a mental health therapist and is also autistic. She intentionally uses identity-first language (rather than person-first language), and invites the reader, if interested, to do further research on the preference of most autistic adults to refer to themselves using identity-first language.

If you are a clinician and interested in learning more about therapy with the autistic client please join me along with two of my colleagues in an online course.
CLICK HERE for additional information about Mental Health Therapy with the Autistic Client.

BY JUDY ENDOW

Endow, J. (2021). Executive Function Assessment. McFarland, WI: Judy Endow.

Endow, J. (2019).  Autistically Thriving: Reading Comprehension, Conversational Engagement, and Living a Self-Determined Life Based on Autistic Neurology. Lancaster, PA: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009b).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2009a).  Outsmarting Explosive Behavior: A Visual System of Support and Intervention for Individuals With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2010).  Practical Solutions for Stabilizing Students With Classic Autism to Be Ready to Learn: Getting to Go. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Mental Health Therapy and the Autistic Client: When Clinicians Don’t See the Autism (Can’t See the Forest for the Trees)

August 8, 2017Autism and Mental Healthautism, mental health and autismadmin

Today, autistic people, just like the population at large, find their way to therapy when symptoms of depression, anxiety, OCD and other diagnoses become problematic to them in their daily lives.

As clinicians we need to understand the autistic operating system – in other words, to see the autism – if we are to be helpful to our autistic clients. When we do not have a strong grasp on this the results are that our clients are not served well. Clinicians without a good understanding of autism generally make one of two mistakes. Last blog discussed the phenomenon “It’s All the Autism” which means once the autism has been diagnosed every symptom from that point forward is attributed to the autism. Today we will discuss the other mistake frequently made by clinicians when they do not recognize the autism.

Can’t See the Forest for the Trees

Over time these clients tend to wind up with multiple psychiatric diagnoses for which none of the typical treatments have been effective in lessening symptoms. These clients’ individual symptoms are sometimes collectively better known as autism, but because one cluster of symptoms at a time presents each cluster winds up meeting the diagnostic criteria for something other than autism. Over time the client collects many diagnoses. However, regardless of how many labels are added, the client tends not to make much overall progress. Effective treatment for individual symptoms cannot be rendered because we have failed to see the autism. Autism means there is a different operating system and that the treatment of troubling symptoms must be delivered in a manner compatible with the autistic operating system.

Example: Ricardo is a 14 year old who’s parents sought out therapy for him because even though he had been near the top of his class academically during middle school, he was now failing some of his classes in high school. Additionally, he had gotten in trouble several times for shoving students. He didn’t have much to say except he was sorry and would try harder to do better.

Ricardo had received an array of services over time. When he was 5-7 years old he received Occupational Therapy for Sensory Processing Disorder. Ricardo did well academically until Fifth Grade when he began having difficulties with angry behavior. He was diagnosed with Intermittent Explosive Disorder and attended both individual therapy and an anger management group. In Sixth Grade he was diagnosed with both depression and anxiety and prescribed medication. Some days it seemed to be helpful, but other days it seemed the medication wasn’t doing anything to make Ricardo’s life better.

During the weeks in therapy several things were discovered. Ricardo was receiving poor grades due to incomplete assignments. It was learned that he had in fact done the science and history assignments, but had neglected to turn them in. He complained that he put everything in his locker, but then couldn’t find what he needed for his various classes. When his mom went to investigate she found most of the missing science and history assignments in his locker along with partially eaten lunches, some missing sweatshirts and a general mess.

Ricardo had difficulty with algebra. He said he couldn’t concentrate because the smell was so bad in that room. It was discovered the boy who sat behind him had stinky feet. Additionally, the boys had just come from gym class and they did not always take showers so the room smelled like a locker room three times a week. While these things were not noticed by most students Ricardo was totally distracted by it. He often missed the assignment when the teacher announced it. When he did hear the assignment he got it done during the classroom work time, turned it in and always got an A grade. He just had so many missing assignments that his overall class grade was a D. When asked what he did during the classroom work time when he was not working on the assignment he said he was just doing the usual – trying to put up with the smell of the room. It did not occur to him that even though the other students were doing the assignment that it meant he should be working on this same assignment.

Ricardo displayed aggression towards fellow students at school. It turned out that much of this aggression was in response to not understanding a social situation and/or in response to anxiety. Typically Ricardo would shove another student in the hallway. Sometimes it looked random in that there was no conversation immediately prior to the shoving. When asked about these incidents Ricardo could only say he didn’t know why he was shoving others, he knew it was wrong and would stop doing it. Then, he would shove someone again. Using cartooning, the shoving was drawn and then, once Ricardo saw it he could contribute more. Eventually it came to light that the shoving was tied to times where Ricardo misread social cues and had thought the student had somehow made fun of him. Then, later in the day, or sometimes even the next day, Ricardo would see the student, know the student was on his bad person list and shove him. The cartooning helped him discover how he knew the student was a bad person.

These were the first clues that Ricardo needed to be evaluated for possible Autism Spectrum Disorder, for which he did meet the criteria. This was important because treating Ricardo for each of the cluster of symptoms that earned him his other diagnoses had not been helpful in alleviating his struggles. ASD better explained the complexity and ushered forth the supports he needed to be successful.

Ricardo was given a check in person at school who assisted him with executive function tasks, developing a system for him to use his assignment notebook and to do and turn in assignments.

When he got the notion to shove another student, Ricardo knew that was something to draw out (cartoon) in therapy and that likely he was missing some social information that others knew (hidden curriculum).

A 5 Point Scale was put in place for Ricardo to manage his anxiety. Over time, with increased social understanding and decreased anxiety Ricardo no longer thinks about shoving others. He did so well that he was able to decrease and then go off his antianxiety medication.

Additionally, Ricardo’s parents started him with an OT who works on sensory regulation strategies. Ricardo now sits near the door in algebra, the location where he is not surrounded by the offensive smells.

As he was growing up the solutions to Ricardo’s difficulties had not been found even though he had received diagnoses at the time of each difficulty – a diagnosis he met the criteria for based on the cluster of presenting symptoms. Once it was determined that ASD better explained his situation than each of the individual diagnoses, the supports could be put in place that would help him be and do what he wanted in his life. It took some time, but once we could see the autism Ricardo could be supported.

Conclusion

When clinicians do not have a good understanding of the autistic operating system they tend to lean toward one of the two mistakes of either attributing everything to the autism or not seeing the autism at all. Neither is helpful in supporting therapeutic progress of autistic clients. The Autistic Operating System, Part Three will delve further into this topic. We will learn about the autistic operating system and how to deliver mental health therapy to clients who happen to be autistic.

(Note: In my practice I see clients who happen to be autistic. Their autism is usually not the reason they seek therapy, but it certainly affects how the therapy for their depression, anxiety or other presenting symptoms is delivered. When mental health therapy is delivered in a usual manner and not based upon the autistic operating system of the client it generally is not very effective.)

BOOKS BY JUDY ENDOW

Endow, J. (2019).  Autistically Thriving: Reading Comprehension, Conversational Engagement, and Living a Self-Determined Life Based on Autistic Neurology. Lancaster, PA: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2009).  Outsmarting Explosive Behavior: A Visual System of Support and Intervention for Individuals With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2010).  Practical Solutions for Stabilizing Students With Classic Autism to Be Ready to Learn: Getting to Go. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Originally written for and published by Ollibean July 30, 2017
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Mental Health Therapy and the Autistic Client: When Clinician’s Don’t See the Autism (It’s All the Autism)

June 27, 2017Autism and Mental Healthadmin

Today, autistic people, just like the population at large, find their way to therapy when symptoms of depression, anxiety, OCD and other diagnoses become problematic to them in their daily lives.

As clinicians we need to understand the autistic operating system – in other words, to see the autism – if we are to be helpful to our autistic clients. When we do not have a strong grasp on this the results are that our clients are not served well. Clinicians without a good understanding of autism generally make one of two mistakes. One mistake is not seeing the autism at all, but instead seeing individual characteristics of autism and matching them with a clinical diagnosis. (The next blog will explore this more.) The other mistake is, once the autism has been diagnosed every symptom from that point forward is attributed to the autism. Today we will look at an example of when clinicians think, “It’s all the autism.”

It’s All the Autism

When a client has been previously diagnosed with ASD it is common for mental health clinicians to attribute all psychiatric symptomatology to the autism, which often results in autistics not being diagnosed or treated for comorbid mental illnesses when warranted.

Example: Elaina was a 9 year-old autistic girl who was in a fourth grade Special Ed classroom. She interacted with her visual schedule tracking her day, which included some General Ed classes along with Speech and OT. She had two friends she ate lunch with and played with at recess. At home, Elaina and her 8 year-old brother each did household chores, participated in dinner conversations about their day and attended church on the weekend.

Elaina started hitting. First she occasionally hit her teachers. Within a few weeks she was also hitting her peers at school and her parents and brother at home. Her family stopped going to church because Elaina could not attend children’s Sunday School class unless one of her parents attended with her to keep her from hitting other children. In fact, Elaina’s life became smaller and smaller as her parents stopped taking her out into the community.

Initially everyone in Elaina’s life attributed the hitting to her autism. The school team worked very hard trying to change this behavior, but to no avail. Elaina saw a psychiatrist who prescribed a psychotropic often used for children with uncontrollable behavior. Other than making Elaina drowsy for a few weeks, the medication did not change her hitting behavior. Whenever anyone asked Elaina why she was hitting Elaina would say, “Don’t hit!” and would say that she would not hit again. The psychiatrist referred Elaina to a therapist.

Over the course of several sessions it was discovered that Elaina suffered from anxiety. When her anxiety felt unbearable she would hit. The hitting ensured people would back off which gave time and space for anxiety to come down.

How was this discovered when Elaina could not tell why she was hitting?

From the first session the context was set using a visual timer and a visual written schedule for the session. Her schedule was the same each time – check in with mom, set timer, therapist’s choice and Elaina’s choice. Elaina had the last 10 minutes to participate in a pleasurable activity of her choice. The therapist provided three choices of activities Elaina enjoyed and that were easily accomplished in the allotted time.

During the therapist’s choice time the therapist would have Elaina recall a specific hitting incident and then cartoon that event. To start Elaina could tell about the act of hitting. Once it was drawn with stick figures and word bubbles, which Elaina was great at making accurate, she was then able to tell other pieces of the incident. These pieces were not told in chronological order so Elaina’s story didn’t often make sense. The therapist took to drawing each piece of the story on a sticky note so Elaina could see it and decide if this piece came before or after the hit. Thus, more and more pieces were elicited. Soon there were enough pieces to tell the story in chronological order so that it made sense.

When there were three such stories the therapist began noticing a pattern so was able to explore the story before the hitting story. Using the same cartooning context Elaina began revealing this story of what was happening for her before the hitting. These sticky notes were a different color and this story was visually placed ahead of the hitting story. Soon the three hitting stories each had a pre story in front of them.

It became apparent that Elaina was experiencing a high degree of anxiety for the half hour or so before the hitting occurred. Therapy then became focused on teaching Elaina and the adults around her the signs of her anxiety, which were subtle, along with teaching Elaina relaxation techniques geared toward bringing her anxiety down. An app was used that read Elaina’s heart rate so she could see it and then watch it come down as she employed one of her relaxation techniques.

Additionally, this app was used for Elaina to check periodically (it was right on her schedule) to see her heart rate. Elaina and her therapist developed a chart that showed which relaxation techniques to use for each heart rate range. Elaina was able to manage her anxiety this way for several months, the hitting lessened and then altogether stopped. She was discharged from therapy.

Three years later, as middle school student, Elaina returned to therapy. Her anxiety management needed some assistance. At that time she was started on a low dose antianxiety medication and her relaxation techniques were reviewed, some revised and some new ones added. The area of mindfulness was explored and added to Elaina’s daily routine. Additionally, new information on the eighth sensory system – interoception – was looked at, along with the interoception activities from the book Interoception: The Eighth Sensory System by Kelly Mahler.

In Elaina’s example it is easy to see that if her anxiety had never been diagnosed and addressed the hitting likely would not have stopped. Alternatively, if a behavioral program had been instituted to stop the hitting without ever having addressed the underlying anxiety, Elaina likely would have learned to replace the hitting with an alternate behavior to help her get people to back off.

(Note: It has been my experience when a behavior is extinguished without understanding and addressing it’s function individuals most often come up with a replacement behavior that is of increased intensity. It serves nobody’s best interest to simply extinguish a behavior, even though this can and is done to autistics quite frequently.)

Conclusion

Next week we will look at the other easily made clinical mistake with autistic clients – when we do not recognize the autism because we can’t see the forest for the trees! Over time these clients tend to wind up with multiple psychiatric diagnoses for which none of the typical treatments have been effective in lessening symptoms. These clients’ individual symptoms are sometimes collectively better known as autism, but because the autism hasn’t been recognized we miss the boat in rendering effective treatment.

Going forward we will delve into learning about autistic operating system and how to deliver mental health therapy to clients who happen to be autistic. Hope to see you back!

BOOKS BY JUDY ENDOW

Endow, J. (2019).  Autistically Thriving: Reading Comprehension, Conversational Engagement, and Living a Self-Determined Life Based on Autistic Neurology. Lancaster, PA: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2009).  Outsmarting Explosive Behavior: A Visual System of Support and Intervention for Individuals With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2010).  Practical Solutions for Stabilizing Students With Classic Autism to Be Ready to Learn: Getting to Go. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Originally written for and published by Ollibean on June 14, 2017
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Mental Health Therapy and the Autistic Client: The Autistic Operating System

May 23, 2017Autism and Mental Healthadmin

Mental health diagnosis and treatment has evolved over time according to what makes sense and what works for most people. We have an increasing body of research around mental health issues that informs us today. However, when it comes to autistic people we do not have a body of research that informs us about diagnosis and treatment of mental health disorders. Autistic people are not like most people. This means we need to understand the underlying autism neurology along with its impacts in the realm of diagnosing and treating mental health disorders in clients also diagnosed with Autism Spectrum Disorder (ASD).

Autism is an Operating System

As a clinician it is important to understand that autism is much more than a diagnosis. Autism is a way of being. It is like being blind in that we cannot separate the blindness from the person, but the blindness – or in this case, the autism – defines the person. As an autistic I see, experience, interact with and give back to the world as an autistic. Autism is my operating system. It defines me.

Autistics have a different operating system than typical people. This is not good or bad. It is just different. Think of PlayStation and Xbox gaming systems. Some gamers prefer one to the other, but most gamers like owning both. This is because some games can only be played on PlayStation while other games need an Xbox system. Neither gaming system is good or bad. They are just different systems.

The majority of the people in the world, because they represent the biggest number, are defined as “typical” and we can say they have a typical operating system. Those with autism are in the minority. They are not wired with a typical operating system. Instead they are wired autistic.

Medically and diagnostically speaking, anything not typical is atypical. This is most of the time helpful, but when it comes to autism it has not proven to be very helpful. Most of the times in the medical field when atypical can be changed into typical this is a good thing so that is the goal whenever feasible. Thus, for years we have tried to change autistic people (whom we assumed to be atypical) into typical people by trying to make them behave like typical people. In the process we have learned that we cannot change the operating system. Autistic people have an autistic operating system.

When Clinicians Don’t See the Autism

Today, autistic people, just like the population at large, find their way to therapy when symptoms of depression, anxiety, OCD and other diagnoses become problematic to them in their daily lives.

It’s All the Autism

Can’t See the Forest for the Trees

Another example is our clients who have multiple psychiatric diagnoses for which none of the typical treatments have been effective in lessening symptoms. These clients’ individual symptoms are sometimes collectively better known as autism, but because the autism hasn’t been recognized we miss the boat in rendering effective treatment.

Conclusion

When clinicians do not have a good understanding of the autistic operating system they tend to lean toward one of the two above examples, neither one being helpful in supporting therapeutic progress of autistic clients. The Autistic Operating System, Part Two will delve further into this topic. Stay tuned in this is an area of interest.

BOOKS BY JUDY ENDOW

Endow, J. (2019).  Autistically Thriving: Reading Comprehension, Conversational Engagement, and Living a Self-Determined Life Based on Autistic Neurology. Lancaster, PA: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2009).  Outsmarting Explosive Behavior: A Visual System of Support and Intervention for Individuals With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2010).  Practical Solutions for Stabilizing Students With Classic Autism to Be Ready to Learn: Getting to Go. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Originally written for and published by Ollibean on May 4, 2017
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Mental Health Therapy and the Autistic Client: Establishing Context

March 30, 2017Autism and Mental Healthmental health and autismadmin

Background Information:

The autism neurology gets hit with elements of confusion, chaos and change as a person goes through their day. How this happens is different for each individual on the spectrum. For example, Brady’s neurology startles to a touch on the arm, DeShawn’s neurology reacts adversely when it perceives a surprise change in the therapy room such as new curtains and Aysia’s neurology delivers a punch when her therapy routine was altered by Grandma bringing her rather than mom.

Each of these individuals was abruptly thrown into a situation with an element of unexpected surprise. It doesn’t matter whether the surprise was good or bad or whether it was a big or small surprise. Most of the time these surprises do not even consciously register, meaning the individual doesn’t even think about them. That is why it is important to understand that it is the neurology that gets hit with the unexpected surprise. This surprise, whether a good or a bad surprise, is often perceived by an autistic neurology as confusion, chaos and change.

For the individual this is most of the time experiential rather than cognitive. It is why they are not able to tell you. Even so, you can see it when it has happened because when the neurology is hit with elements of confusion, chaos and change it has the effect of knocking a person off kilter! We definitely can see these results. Brady jumps up out of his seat after an unexpected touch on his arm by another group member walking by, DeShawn won’t enter the therapy room the first time he notices the new curtains and Aysia is giggly and cannot settle down to any therapy work.

Establishing Context During the First Session

The experience of confusion, chaos and change can be managed in a context of predictability, sameness and routine. This is why it is important to construct therapy sessions using a framework of predictability, sameness and routine for our autistic clients, regardless of their comorbid mental illness or the therapy goals we are working on.

We can do this beginning with the very first session. Here is an example, using a recent intake session for a client who would return regularly.

Zak, 17 year old high school senior came with his parents for intake. Previous paperwork had been filled out and returned so I knew Zak wanted help with getting homework done, stopping online game playing when he wanted to be finished and not having his mom get him up in the morning.

At the start of the session I explained the therapy hour was 50 minutes and set the visual timer to coincide with the end time of therapy. I explained that each time Zak came I would stand the therapy session clock (visual timer) up on the filing cabinet and we all would know that when the red was gone our work for the day would be over.

I then used a dry erase board to list the activities of the session. I wrote down understand and sign Informed Consent, understand and sign Cancelation Policy (two forms that had not been returned with the rest of the intake packet) and list at least three therapy goals. I drew lines with bullet points for three goals (since I knew the three items from the intake packet) and then by the fourth bullet point lines I put a question mark. This visually left space in case anything new came up during the session. In addition I wrote Treatment Plan at the bottom of the list on the dry erase board.

Zak asked if he could have the dry erase board and he put it on the arm of the couch next to him. After each of the first two forms was signed I told Zak he could cross out or erase that item. He chose to cross out each of these items as they were completed.

I then had both Zak and his parents tell what they hoped Zak would get out of coming to therapy. This discussion took up the bulk of the session. Near the end of the discussion I asked Zak if he would like to write the therapy items on the dry erase board or if he would like to tell me and I could write the items down. Zak responded by picking up the dry erase board and writing in what he wanted to work on during sessions and the items corresponded to what had been expressed both during the session and on the intake paper work that had been sent in. The items Zak wrote on the dry erase board were incorporated into his Treatment Plan.

By using a visual timer to track the session and allow us all to see the ending that was coming along with using the dry erase board to write in the agenda for the therapy hour I was effectively setting the context of predictability, sameness and routine for future therapy sessions. This is one easy way to establish that context and I often use it in mental health therapy sessions when the client happens to be autistic.

Additional Ideas

Other examples of establishing and using a context of predictability, sameness and routine include, but certainly are not limited to:

Setting timer and having client write down what topic they wish to discuss that day (for clients who are readily able to express themselves by talking).
Having three activities, each of which will move the client along in working toward their therapy goals and client gets to choose which one to do first, second and third. Client erases or checks off each activity upon completion.
Some clients need more of a choice so I might show two choices per therapy goal. For example, if the goal is to identify feelings (8 year old client) the choices might be to play a feeling game or to do play-acting (where an assigned feeling based scenario is acted out between therapist and client). Either of these choices would move the client along toward this therapy goal and yet give the client a choice between two activities.
Using the framework of a sentence at the top of a blank piece of paper such as:Today I want to show and/or tell you about: ____________________________

Conclusion

Regardless of how you choose to establish a context of predictability, sameness and routine with your clients, it will go a long way in supporting your client down the road when more difficult topics tend to arise during the course of therapy. I have had some clients report to me they were able to bring up emotionally charged topics because they could see the timer and know when the session would end. Others have reported they thought about what they would write on their paper ahead of time and could do so because of the familiarity of doing this at the beginning of each session. One client told me the paper gave him a place to put his thinking words.

BOOKS BY JUDY ENDOW

Endow, J. (2019).  Autistically Thriving: Reading Comprehension, Conversational Engagement, and Living a Self-Determined Life Based on Autistic Neurology. Lancaster, PA: Judy Endow.

Endow, J. (2012). Learning the Hidden Curriculum: The Odyssey of One Autistic Adult. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2006).  Making Lemonade: Hints for Autism’s Helpers. Cambridge, WI: CBR Press.

Endow, J. (2013).  Painted Words: Aspects of Autism Translated. Cambridge, WI: CBR Press.

Endow, J. (2009).  Paper Words: Discovering and Living With My Autism. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2009).  Outsmarting Explosive Behavior: A Visual System of Support and Intervention for Individuals With Autism Spectrum Disorders. Shawnee Mission, KS: AAPC Publishing.

Endow, J. (2010).  Practical Solutions for Stabilizing Students With Classic Autism to Be Ready to Learn: Getting to Go. Shawnee Mission, KS: AAPC Publishing.

Myles, B. S., Endow, J., & Mayfield, M. (2013).  The Hidden Curriculum of Getting and Keeping a Job: Navigating the Social Landscape of Employment. Shawnee Mission, KS: AAPC Publishing.

Originally written for and published by Ollibean on March 29, 2017.
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