"working with modes in individuals with autism spectrum disorder across the lifespan: a cross-section of cases"
case discussion by erin BULLuss, ida shaw & maria Galimzyanova
This case series presents methods for working with modes relevant to age and autism-spectrum symptomology across childhood, adolescence, and adulthood. These cases have established diagnoses of Autism Spectrum Disorder (ASD) and share not only underlying schemas of defectiveness, mistrust, and alienation, but also overcompensating coping modes, specifically bully-attack and paranoid over-controller mode.
The role of early intervention and support networks in guiding healthy mode development is discussed as well as the importance of accepting ASD and focusing on meeting both emotional and sensory/neurological needs associated with ASD, rather than “fixing” ASD.
The emergence and presence of punishing/demanding critic modes in the three cases will also be discussed. The first case is a 7 year old boy who was diagnosed with high functioning ASD at an early age and had his needs met appropriately within his family of origin. However, his needs were not being met within the school environment and he began to see himself as the “bad guy”, was highly mistrustful of teachers and most students, and often felt both left out and picked on. He subsequently developed a bully-attack mode to assist him to feel safe, as the socio-emotional skills required to negotiate the school yard and interactions with teachers were significantly under-developed. His obsessive interests were used to build a therapeutic alliance and engage him in mode work and socio-emotional skills building. A systemic approach was concurrently adopted to assist the school to better understand him and meet his needs, consequently reducing bully-attack mode.
The second case is a 14 year old boy with mild intellectual impairment, who had only recently been diagnosed with Autism Spectrum Disorder at the commencement of therapy. Given his relatively late diagnosis, for many years his ASD was not understood or catered for in the home environment or schooling system. He felt different and on the outer but without a framework to understand why this was so. There was also a mismatch between the standard schooling system and his sensory/neurological needs, which led to him feeling highly mistrustful of school staff and the majority of students. He developed bully-attack and paranoid over-controller modes in order to feel safe, however they perpetuated his sense of defectiveness and alienation. He also had begun to develop a strong demanding critic mode. Puppets and storytelling were used to implement mode work, and a systemic approach was also taken to create a trusted network of adults at home and school who could be relied upon for guidance and protection to reduce overcompensating modes. The alliance created across environments allowed an increased sense of safety to reduce bully-attack mode while building a wise side through socio-emotional skills building.
The third case is a 35 year-old man who was diagnosed with high functioning Autism Spectrum Disorder at 16 years of age. His late diagnosis meant that his needs were not properly understood or appropriately met within home, school, and health-care environments. Consequently, he developed a strong sense of being let down and mistreated across numerous contexts, not fitting in, and being “bad” and different. At the commencement of therapy he primarily flipped between paranoid over-controller mode and punishing/demanding critic mode in sessions, and outside of sessions his bully-attack mode would spend time planning violent attacks “just in case.”
Therapy began by slowly building trust within the therapeutic environment, labelling modes as they appeared, explicitly describing how it felt in the therapist’s chair when different modes were present and detailing the impact of each mode on the therapeutic relationship. Once the relationship was strong enough, the focus was on uniting to banish his punishing/demanding critic mode through visual and experiential therapeutic techniques, such as mode dialogues and imagery rescripting. Once the critic mode was banished his vulnerable child mode began to present frequently in sessions, particularly the “broken/bad” vulnerable child mode. This phase of therapy incorporated play based techniques to implement mode work while providing a corrective experience of shared play (rather than solitary play). Imagery rescripting was introduced used metaphors consistent with his interests. A heavy focus on acceptance of ASD symptomology, and some exploration of ASD specific needs while working to meet core emotional needs was also a part of this treatment phase.
Once he felt less “broken/bad” and began feeling more worthy of recovery, time was spent working with paranoid over-controller mode and “mistreated/lonely” vulnerable child mode until he was willing to begin developing a professional and social network to increase his sense of safety. This phase of treatment could potentially be viewed as a systemic limited re-parenting. Creating an “ASD friendly” system to meet emotional and sensory/neurological needs appropriately was an important part of the intervention for the first two cases presented to illustrate childhood and adolescence. When the experience of a guiding, nurturing, protective system was absent during formative years, it appeared to impact upon the willingness of the individual described in the third case to seek appropriate supports during adulthood. This lack of systemic support then increased isolation, vulnerability, and sense of unsafety, and fuel overcompensating modes. As such, the use of both individual therapy and systemic approaches when working with adults on the autism spectrum will be discussed.
Discussants will address methods of applying Schema Therapy with ASD.
Expected points for discussion –
1. Linking mode work to intense interests to facilitate engagement.
2. The importance of ASD informed support networks across contexts in formative years (and as a systemic limited re-parenting later in life)
3. Potential aetiology of modes and benefits of early intervention to guide healthy development.
4. Incorporating ASD specific knowledge and understanding into implementation of mode interventions.
5. Acceptance of ASD neurology as a core feature of limited re-parenting with ASD populations.
1. Ida Shaw
2. Maria Galimzyanova
ERIN BULLUSS is a Clinical Psychologist in private practice in the Adelaide Hills, South Australia. She completed a PhD (Clin Psych) at Flinders University in the area of early intervention for core-deficit linked behaviours in children on the autism spectrum, her research was published in “Autism: The International Journal of Research and Practice” and presented at local and international conferences.Erin has been accredited by AutismSA to formally diagnose Autism Spectrum Disorder in individuals in South Australia, was a behavioural therapist and research assistant for a number of years at the Flinders University Early Intervention Program, and has been involved in designing and implementing a skills based treatment group in the public sector for adults with special needs who had committed sexual offences. Erin combines her experience diagnosing and managing autism spectrum symptomology across the lifespan with her practice in Schema Therapy to find creative, experiential, and concrete methods to engage neurodiverse individuals experiencing complex comorbidities in mode work.
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