What ALL Therapists Need to Know About ASD!
A Strengths Based Approach to Autism: What Providers Need to Know and Don’t!
It is virtually impossible not to focus on one’s deficits if you are among those who have received dozens of differing diagnoses by countless treatment professionals, who are prescribed up to 20 different medications annually, from mood stabilizers, and antipsychotics to stimulants and benzodiazepines, who experience a laundry list of worsening symptoms, and left to perpetually ask, “what is wrong with me?” (Rashid, 2015; Curnow et al., 2023; Vohra et al., 2016). Those for whom an exploration of abilities and strengths are stymied by the persistent need to advocate for their deficits in the hopes of one day being understood by those around them (TedX Talks, 2018; Silberman, 2015; Grandin,2010). An effort that almost always fails, due to the very neurodivergence that compels these difficulties to begin with, and that loved ones, institutions, and even providers, are ill equipped to recognize or treat (Fung, 2021; Ousseny et al., 2015). A group often so overcome by depression and anxiety they are unable to see the resilience they possess in abundance, a resilience that according to Rashid (2015) must be “nurtured” to “buffer against their psychological disorder” (p. 515). This is precisely the starting point for many adults with Autism Spectrum Disorder (ASD) without intellectual difficulties, who have gone undiagnosed for years or even decades (Fung, 2021; Rudy, 2024; Curnow, et al. 2023; Gesi et al., 2021). A group now believed to comprise 20% of the mental health treatment population at any given time, and that have contributed to a 175% rate increase in the diagnosis since 2011 (Center For Disease Control [CDC], 2024; Curnow, et al. 2023; Gesi et al.,2021; Ousseny et al., 2015). A group that is nine times more likely than the average person to experience suicidal ideation (66%), 35% of whom have had these thoughts dating back to early childhood (<8-year-old), 30% of whom admit to having had a suicide plan or having made an attempt, and that are three times more likely to die from a suicide attempt (Cassidy et al., 2014; Schwartzan et al., 2021). This group, adults with ASD, those without intellectual difficulties, who have been, and remain, invisible to many adult treatment providers, and are frequently left traumatized by the very system they have turned to for help, may benefit most from a strengths-based assessment approach (SBA), one that can help them to overcome the intense sense of disconnection, isolation, and near constant focus on deficiencies, that they have become so accustomed to (Fung, 2021; Raja, 2014).
Though it is now estimated that 1 in 68 children are born with ASD, our social and clinical understanding of the condition remains archaic (Silberman, 2015; Grandin, 2010). Stigma related to an obtuse, and powerful mischaracterization of the illness, ignorance as to the many expressions, presentation, overlap, size, and scope of symptoms, and the tendency for those with ASD to ‘mask’ or hide symptoms, remain impediments to accurate diagnosis and treatment (Zerbo et al., 2015; Gesi et al, 2021; Ferguson, 2022). This is particularly true for those who do not experience intellectual difficulties, who appear to the outside world, therefore, to be ‘normal’ (Rudy, 2024). Symptoms of ASD in adulthood often overlap with symptoms of schizophrenia, schizoaffective disorder, bipolar, ADD, ADHD, OCD, anxiety, depression, insomnia, and borderline personality, to where misdiagnosis is exceedingly common (Gesi et al., 2021). To underscore the magnitude of this problem and its effects, Gesi et al. (2021) found 80-90% of adults diagnosed with ASD to have been misdiagnosed, and 75% to have received their diagnosis an average of eight years after their first mental health evaluation. A comprehensive study conducted by Ousseny et al. (2015) of 922 physicians found the overwhelming majority to have little to no knowledge of ASD’s presentation, and to have failed to recognize they were actively treating patients with ASD at the time. An ignorance on the part of the treatment community that leads not only to the facilitation of the worsening of symptoms, but to incredible medication mismanagement, with approximately half of adults with ASD prescribed six or more classes of prescription drugs per year (Vohra et al., 2016). A problem that only exacerbates symptoms, confuses client’s and providers further, and erodes all trust and faith in treatment (Ousseny et al., 2015; Hellings, 2023; Rudy, 2024).
A Movement Away From Pathology
Recognizing the dire need for change, those in and around the ASD community have begun to use the term “neurodivergent” as a non-stigmatizing way to reframe autism, as a way to “describe people whose brains develop or work differently”, as opposed to those who have a disease, illness, or a disorder (Silberman, 2015; Cleveland Clinic, 2024, para 1). This reframing of ASD is evidence of an advocacy movement largely propelled by those within the community, to focus on education, awareness, and the dispelling of unhelpful notions of autism that date back to the 1940s (Kanner, 1943; Silberman, 2015; Grandin, 2010; TedX Talks, 2018). Central within this recharacterization is the acknowledgement that treatment must shift its focus away from comparing a client’s experience against what is considered ‘normal’, or pathological, and rather onto uncovering strengths, talents, capabilities, skills, and interests, the celebration of an atypical brain (Fung, 2021). Recharacterizing ASD in this way acknowledges that while those with ASD may experience life differently from what is considered normal, there are a great many benefits, capabilities, and strengths common to those on the spectrum (Fung, 2021). To underscore this point, Fung (2021) points to contributions from historical figures such as Albert Einstein, Sir Isaac Newton, Michelangelo, and Andy Warhol, those believed to have been on the autism spectrum. In addition, Fung (2021) presents the results of an assessment of ASD experts who report traits such as trustworthiness, having strong moral character, a sense of humor, and values, such as loyalty, honestly, and kindness, to be among the most common traits to those with ASD.
This strengths-oriented movement evidenced by the reframing of ASD also mirrors psychology’s decades long effort to move away from the medicalization of mental health, to infuse a more humanistic, strengths-based approach into psychotherapy (Szasz, 1974; Rashid, 2015). A shift away from the inherently disempowering biomedical model that purports determinism, away from over pathologizing, or a reliance on arbitrary labels and categories representative of deficiencies, those that reduce experience to that of a “Google search” (Rashid & Ostermann, 2009, p. 489; Rashid, 2015). This strengths-based movement instead acknowledges one’s power to construct their experience by making changes to one’s focus, thoughts, actions, decision-making, and affect (Rashid, 2015; Jones-Smith, 2024). A shift in treatment that acknowledges “strengths contribute to well-being in the same way that weaknesses contribute to psychopathology” (Rashid & Ostermann, 2009, p. 489).
The Practical Application Of SBA
Strengths-based assessment (SBA) is not a type of treatment, per se, but a way of being that is exuded through one’s clinical work and that can be applied to any modality of treatment, at any time in the process, regardless of the type of treatment engagement, from intervention, to assessment, to a short-term or long-term psychotherapeutic engagement, from group and family work, to couples and working with individuals one on one (Rashid, 2015; Madsen, 2017). SBA is not solely a reference to the assessment or intake aspects of treatment but refers to the concerted, conscientious, and embodied way in which a provider focuses their attention, engages with the therapeutic process, and the client (Rashid, 2015; Madsen, 2017). An approach that is goal-directed, collaborative, focuses on building a shared perspective, or developing an awareness of the client’s constructed reality to include culture, perception, beliefs, meaning, language, etc., that is non-judgmental, and holistic (Rashid & Ostermann, 2009; Rashid, 2015; Madsen, 2017). SBA considers all aspects of one’s life including, experience, behavior, decision-making, environment, relationships, affect, and the human design, all in an effort to forge a pathway forward that improves one’s life (Rashid, 2015). SBA requires a wholehearted effort to join with the client’s experience, as opposed to projecting meaning and extrapolating conclusions from the ‘expertise’ of the provider (Rashid, 2015; Madsen, 2017). SBA is empowerment focused, and seeks to expose the needs, wants, strengths, abilities, and resilience of the client (Rashid & Ostermann, 2009). While strengths-based assessment includes the perpetual scanning and listening for strengths (such as looking for evidence of “flourishing”, and positive attributes, etc.), the critical focus remains the nurturing of the relationship with the client (Rashid, 2015). A client-centered engagement that seeks collaboration, and equity, while exuding empathy, respect, unconditional positive regard, active and attentive listening, and following the client’s lead from start to finish (Rashid, 2015; Rashid & Ostermann, 2015). SBA calls for a persistent shift in focus from problems to abilities, and ‘assets’, from ruminating on symptoms to highlighting resilience (Rashid & Ostermann, 2009; Rashid, 2015). Reflecting on one’s history, not to find where things went wrong, but to seek out the triumphs, in search of the guidance and wisdom they provide, to help facilitate insights into how to navigate the difficulties of the present, and to reinvigorate a client’s hope for a more positive future (Rashid, 2015; Rashid & Ostermann, 2009). It is with these key aspects of strengths-based assessment in mind, that it becomes self-evident why and how an SBA approach is valuable for adults with ASD, valuable for all who believe they have lost their ability to see their inherent worth.
Addressing Suicidal Ideation
Among the more disconcerting outcomes that has arisen from this assignment is the realization that the ASD population, and their increased risk for suicide, is underappreciated within the treatment community (Raja, 2014). Recognizing clinicians cannot afford to be wrong, I am left to conclude that providers must be prepared for a crisis intervention in every clinical engagement, as there may not be overt warning signs as one might anticipate. For example, Raja (2014) found that suicidal ideation was not found to correlate with a history of depression, particularly among those with an ASD diagnosis. The responsibility, therefore, is placed solely on treatment professionals to develop the “art” of suicide risk assessment, to use our tools, be educated as to what to look for, and confident enough in our assessment ability as to not have to rely solely on the outcome of suicide screening tools to detect any potential threat (Sommers-Flanagan & Sommers-Flanagan, 2021, p. 49). As Rashid & Ostermann (2009) recommend, therapists should seek to be “flexible… incorporating both qualitative strategies and objective measures, integrating strengths with weaknesses” (p. 497).
When assessing for suicide risk, a strengths-based assessment approach, is itself a powerful intervention that attends to the needs of those at the greatest risk. Though there are no universal warning signs of suicide, it is well established that as Sommers-Flanagan & Sommers-Flanagan (2021) explain, those who experience “suicidality also feel socially disconnected, emotionally invalidated, and as if they are a burden”(p.66). Through the therapist’s unrelenting focus on fostering the clinical relationship through unconditional positive regard, validation, empathy, and understanding, SBA offers client’s a meaningful sense of connection, a sense of being heard, and the experience of being emotionally validated, without efforts to be talked out of their thoughts, feelings, or experience, or shamed and guilted by their honesty (Sommers-Flanagan & Sommers-Flanagan, 2021: Rashid, 2015). Additionally, through asking the right questions, balancing one’s focus on symptoms with assets, and seeking to normalize the client’s experience without being dismissive of an admission of suicidal ideation, self-injury, or high-risk behavior, an SBA approach supports the client’s most pressing needs implicitly discouraging the desire to take action (Sommers-Flanagan & Sommers-Flanagan, 2021).
Sommers-Flanagan & Sommers-Flanagan (2021) also propose a complex and integrated dimensional model for understanding the factors that influence suicide risk. By attuning to these dimensions, providers are better able to understand the varied influences impacting their thoughts, emotions, experience, and behavior, and, therefore, are better equipped to support the client out of harm’s way (Sommers-Flanagan & Sommers-Flanagan, 2021). According to Sommers-Flanagan & Sommers-Flanagan (2021) dimensions are broken down into the emotional, cognitive, relational, cultural-spiritual, physical, and contextual aspects of the client’s inner experience. Dimensions that therapists can use, in a number of strategic and artful ways to navigate their client away from harm (Sommers-Flanagan & Sommers-Flanagan, 2021).
Importantly, Ingram (2011) underscores a component of suicide prevention that must also be mentioned and considered when evaluating a client at risk, “countertransference… if unexamined, might lead to inadvertently sending the message that you wish the client would disappear” (p. 123). Simply by embodying the SBA approach, and, thereby, honoring the importance of connection, this oversight, however, would not be possible. Ingram (2011) also recommends involving family or loves one’s (when and if it is appropriate to do), contracting with the client to ensure their safety, having a plan for combating negative self-talk, staying focused on activities, being more engaged with others and out in the world, and identifying warning signs for the worsening of symptoms as other possible interventions. Additional factors such as seeking out community based on shared interests or activities, nurturing one’s interests and activities (free from judgement), and allowing client’s to explore what is important, interesting, and of value to them, are also aspects of SBA that can be leveraged in treatment (Rashid, 2015; Jones-Smith, 2024, Ingram, 2011).
Conclusion
Adhering to SBA in clinical practice requires self-reflection, awareness, and insight, an accurate assessment of oneself, and the ability to allow (and model) absorption and engagement, an uncompromising commitment to being present, and focused on the therapeutic process (Rashid, 2015). This means being engulfed within and attentive to the culture, meaning, and experience, the reality, of the client. This also requires, however, the disavowing of any strict allegiance to standard clinical practice, one that requires the continual scanning of the client’s presentation for deficits in accordance with a deterministic view of psychopathology (Rashid & Ostermann, 2009). One that looks to treat clients in accordance with overly simplistic, and largely arbitrary, diagnostic categories determined on the basis of societal standards (Szasz, 1974). It is through my own firsthand experience, and research, that I can say with certainty this approach has caused and perpetuates the many difficulties adult client’s diagnosed with ASD have and will continue to face. That is, to be incorrectly diagnosed and medicated, to spend years falling through the system’s proverbial cracks, victimized simply by the limitations of the scope of practice of too many clinical professionals. Therapists must take care to be aware of the human tendency to define clients based on whatever analysis most closely matches our prior knowledge, experience, training, and interpretation of diagnostic categories (Rashid & Ostermann, 2009). This also, however, precisely speaks to the value of an SBA approach, one that looks to reshape the focus of treatment away from what is ‘wrong’, towards how to strengthen what is ‘right’, and leverage these favorable aspects to promote “flourishing”, a movement away from the overidentification with one’s psychic pain and suffering, in favor of the co-construction of a more satisfying meaningful future aligned with the client’s needs, goals, and desires (Rashid & Ostermann, p. 493).
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