What is autism?
Autism is a neurological disorder that presents challenges for individuals in social behavior (understanding social cues, knowing how to initiate conversations, maintain conversations, knowing how to reciprocate, engaging in appropriate eye contact) and the presence of repetitive or rigid behavior. It has been increasing in prevalence in the United States and is estimated that 1 in 59 children are diagnosed with autism spectrum disorder (ASC). According to CDC’s Autism and Developmental Disabilities Monitoring; adults with autism primarily seek help from licensed psychotherapists due to challenges related to anxiety, depression, and other psychiatric symptoms that can lead to other distress in their life. At Crimson Counseling our client focus is with teens and young adults with autism and to help them become independent and reach their objectives with social, vocational, and mental health goals. These individuals are able to create social abilities and individual development, with treatments of psychotherapy and ABA.
Experiential Therapy and Adventure Based Counseling
For teens and young adults the use of experiential and adventure therapy is an experiential approach to build self awareness of how they interoperate their environment emotionally. Experiential therapy is the relation between the client and the experience allowing the clinician the ability to facilitate or create a positive behavior change and to open them up to express feelings, fears, sometimes unknown even for the patient. This type of therapy involves activities and experiences, not just the “traditional talking”, with the intention to explore the subconscious issues with the individual and give its attention to the activity that is being executed.
This type of approach can boost the relation between the client and the experience and provides a strong relation between the clinician and the client because of the reinforcement with the relation with the experience for the guidance that the clinician provides between this experiences, giving an opportunity to the therapist to work as a companion helping in the difficulties that may present, making a valuable progression in the determination of obstacles, the experience and awareness of successes, the development of self- esteem, confidence and giving a giant step in the consciousness of the responsibility they have on their own actions; also the therapist can begin to develop the focus abilities thanks to the empathy in the relation client-therapist giving a possibility of a reflection from part of the patient and allowing the professional to take place the inner focus, for example, pausing the activity and pointing out something, making the client indirectly to focus their attention in it.
This approach has a lot of benefits in the patient’s life, the intervention of the specialist during or after the activity about the behavior and decisions that are taking place in the activity is more likely to give the patient emotional growth and personal awareness, making reachable the intention to work on the own potential awareness and patient with this experience is more likely to evaluate the behaviors that have taken place in the activity and recognize its consequences, giving a self-image of what he/she can do. It can be said that as a secondary goal for some patients this type of therapy provides a new way of filling the “down times” during they daily living, reaching psychiatric symptoms like depression, and anxiety.
The Adventure Based Counseling (ABC) can be used as a tool with Experiential Therapy that involves, group counseling, outdoor education, and intrapersonal exploration. This approach uses psychosocial and educational theories with an individual, group, and familiar counseling with the distinction that involves the real risks, the ethical considerations, skills and metaphors that will finish in the learning of the inner aspects of the individual. The ABC is principally the use of the usually called “Soft-skills” of the traditional counseling with the skills related to adventure like hiking, rope courses management, climbing to present this real risk in group activities. The selection of activities is essential in the ABC, there are 6 styles of facilitation for the realization of macro-processing, there is no loading, front loading, back loading, front-back loading, metaphors, and paradox, after this experience-based learning the concepts have to be transferred from the activities to the real life.
This theory application pass through a process where the therapist will use a lot of well-known theories such as cognitive theory with the intention to understand the way the experience affects the individual and the group, the Rational Emotive Behavioral theory that involves the perception of risks, Reinforcement Theory act in the inner emotions of the individual, Reality theory with the objective of taking responsibility of the decision and actions that we take on the present.
One of the most important theory involves the Gestalt theory to process these experiences while they are occurring, creating new skills based on the activities that are happening at the moment; also, Narrative theory writing a person’s “story”, added with a Constructive approach to earn the realization of making the individual creates his/her own story is part of the individual approach in cases that can help with these teens and young adults, this therapy has outstanding results in the improvement of independent living, positive self- concept , self- efficacy and the improvement of social skills overcoming all the psychiatric symptoms involved in every individual. One of the most important facts to notice is the possibility to get more information about one’s personality, Kimball (1983) described that this wilderness program was similar to any projective test, for the information that the client can provide with the person’s response to the challenges presented in the process, giving the therapist a global vision of the individual.
The group and family interventions are important to create skills around other people, such as diffusion anxiety with others, decreased defensiveness, distributive leadership, and boost the experimentation; the ABC has led to big advances in cases where the objective has been to restructure the client orientation to the social interactions with other individuals involving life cycle issues, context of lifestyle and give a perspective about being an independent individual ; as an educational theory this approach is based on the experimental education that is basically “learning by doing” and the experience of learning with others has the positive achievement of dimensions of trust.
The transfer of knowledge to the individual from the activity is one of the main topics in this counseling, and the base in which its formed is with lineups to follow like; the opportunities provided to the client, the natural and not artificial form of the experience, the reflective thinking to internalize the learning, the design and follow up of the participants to provide a good and organized interactions with the problems.
The program presents a good number of benefits, like the goal setting becoming a “recipe for success” with the correct lineups in every case, trust building giving an effective way to build gradually trust through activities that will require more or less level of trust from the client developing complex inner confidence.
This type of therapy has been controversial through the years for Autism Spectrum Disorder due to the difficulties in the direct communication with the counselors. The approach with Experiential and Adventure Based counseling has closed the gap between the Psychotherapy and this kind of Disorders. Psychotherapy is based on the conversation between individuals in a one on one, group or family sessions when the main goal is to achieve communication about feelings that the individuals have with themselves or about the people related to them; the psychotherapy and the spectrum of this disorder lead us to specific treatment methods and approaches in these clients; (Stern,1995) stated, with Mahler approach where the psychoanalyst was starting to add their mother to the ground, that the introduction of dyadic and triadic treatments were a portal of entry to the children world, and as any treatment directed to young children involves normative, adaptive and developmental factors to be noted. For these clients, the psychotherapeutic approach has to involve all the pluralism of therapeutic designation for the cases.
Cognitive Behavioral (CBT) approaches in autism disorders is a really powerful tool, it uses the cognition or the mind of the subject with a systematical approach to symptoms like anxiety, depression and emotional difficulties. The CBT approaches the feelings that reside in the subject developing specific changes of the thinking of every individual that in this broad spectrum of autism can lead to the person believing things that can affect the symptoms such as difficulty on the social support, or anger problems. The principal objective is to identify and start with every individual goals and passion to identify the track of the treatment, for this the approach to ASD patients have to be personalized and set to a bigger goal like developing the social and cognition abilities of the patient; some of the treatment specializes in the social interactions that have to be achieved by the guidelines to develop self-acceptance and mitigation of the things that cannot be changed in the individual, also to recognize patterns that affect the anxiety, stress, and depression, becoming a tool preventing the start of this symptoms.
In 2012 a study showed that child’s with ASD are really receptive to the different modifications that can be used in CBT revealing an almost complete recognition of thoughts, feelings, and behaviors, and even revealed a good reception and achievement of changing the ones that were a trouble for the patient and the family; working in groups also reveals the realization that other people are having the same problems, the family approach along the psychodynamic dialogues with the therapist and even using a triadic approach depending on the response of the child to the parents, and the parent response to the behaviors of the child, can be the correct way of treatment. Some of these patients, not all, present some fantasies that can be a restriction on the analysis, but this approach including the parents’ mind can be used for the therapist to reconstruct with the interactions that this intervention can present. The autism individuals have, very variable, mental patterns and tendencies that restrict some of the range of action in the treatment, but the imaginative life and fantasies that are part of specific personal experiences should be examined and reconsidered in the dyad or triad treatment. There have been studies showing the positive outcome of the treatment on the patients, especially in anger management issues, social skills development, panic and anxiety disorders and depression. The early intervention benefits are well known, and this type of treatment approaches can lead to a powerful tool on developing the main goal of every individual, becoming more aware of responsibilities, social skills, and the good path to identify and develop the feelings and thoughts in every case.
The Acceptance Commitment Therapy (ACT) is a behavioral treatment that has its premise in the ability to act based on the feelings and thoughts recognized by the individual in a concrete behavior aligned to the values that are part of every client. The aim of the ACT is self-acceptance of every experience, good or bad, and the actions that we will take on this experience. The connection is one of the most important things in this approach, the relationship between the therapist and the individual has to be strong to get realistic goals and good understanding of the state of the patient, in this therapy the part of the therapy is to become a, or a support on the self-knowledge of the stimuli that connects with the behaviors and regulate them creating new rules and new environments to motivate the client to approach to behaviors in base of this experiences.
The language and the experience knowledge are big parts of this treatment that can be developed with these modifications of the rules and environments, to begin accoupling the social abilities and the solution to personal problems, this keeps direction to the development of the skills and abilities to overcome the deficit on social or comprehensive behaviors and capabilities of individuals with the use of metaphors and stories increasing the Mindfulness in all the aspects that were recognized in the connection with the client.
Mindfulness-Based Therapy (MBT) is a tool that can be compared to CBT in the interaction with the feelings, despairing in the fact that MBT is directed to identify and accept the feelings while they are happening but without the analysis of them; this acceptance of the feelings is reached with experiences of activities without discussing them and recognizing them in a way that doesn’t have the objective to make changes on them. This treatment has been leading to excellent results in the improvement of social interactions, concentration, impulsive behavior and happiness; this focus on just accepting the feelings in a non-judgmental way has reported in many studies a significant decline in anxiety, depression, and rumination. This approach can be attached to the Adventure Based Counseling becoming a powerful tool to overcome disabling symptoms on ASD, and developing a wide range of skills that allows the patient to reach their goals and develop their potential.
Applied Behavior Analysis (ABA) in Autism Disorder Spectrum
ABA has a structure based on behaviorism that is the idea that the psychology can be explained through the objective study without giving attribution to internal processes, it means, that ABA uses the analysis of factors that may influence behavior; it has a set of principles to include general “laws” with the objective to reduce harmful behaviors that interfere with learning; as a general definition the behavior is anything, including the accepted and not accepted skills and actions, that the individual does in relation to the context presented to him/her.
ABA investigate the interactions with the environment and all the factors involved, to decrease inappropriate behaviors and increase the appropriate behaviors on any social context. This Analysis is accepted as an evidence-based resource, that means that it has passed scientific tests of quality and effectiveness, that has many different techniques focused on the antecedents and the consequences of the subject to a specific situation, or the environment.
The evidence-based practices are essentially the fundamental interventions applied in ABA in a systematic way and have been evolving to become part of the delivery of the process for ASD in many ways. Some studies supported the efficacy in the implementation of processes like:
Antecedent Based Intervention (ABI)
Is the arrangement and modification of different circumstances in the environment/ context that precede the behavior in a way that leads to the reduction or the complete change of this behavior. Once the problematic circumstances have been identified the implementation of ABI it can modify the behavior of the subject; there are various forms of ABI to be implemented that can help to reach the main goal, essentially, the implementation of changes in the schedules, the preparation around the activity that will be done, the variation of difficulty in the activities and the characteristics that can enrich the environment around the decisions of the patient are some of the ways to implement the ABI leading to a positive outcome.
According to the outcomes of recent studies, this intervention helps from ages 0-2 years toddlers to 19-22 years young adults with ASD; and the outcomes revealed development in social communication, behavior, academic, motor and adaptive skills.
Differential Reinforcement of Alternative, Incompatible or Other Behaviors (DRA/I/O)
Is based on the provision of positive consequences for desired behaviors or the reduction of the not desired ones with the objective to attack the behaviors that interfere with their learning, development, health, etc.
The reinforcement is provided in a differential way; this will be provided when the behavior is desirable (DRA) and the not desirable behavior is not present, when there is an incompatible behavior (DRI), or when the not desirable behavior is not being engaged (DRO). The results from precedent studies suggest that it has been really effective in patients with ASD between the ages of 3-22 years, and this intervention can address to social communication, behavior, attention, playing, academic, motor, and adaptive skills.
The exercise is the implementation of physical exertion with the goal to reduce the undesirable behaviors or the development and increasing the physical fitness and motor skills in order to increase the desirable behaviors, this can be done indoors and outdoors and usually involves a warm-up and a cool-down between the exercise. This intervention has been effective for ages 3-14 years and addresses academic, motor and adaptive skills.
It is based on accurately identifying the function of the behavior and the consequences that may be increasing the repetition of the behavior, this way removing the consequence that may be affecting the challenging behavior. Commonly this challenging behavior increase initially before the complete extinguishing, this is usually referred to as the “extinction burst”. This intervention must not be used in isolation. This treatment has reported effectiveness in ages 3-18 years and focus on the social communication, behavior and adaptive skills.
Functional Communication Training (FCT)
The FCT involves the systematic practice to replace inappropriate behaviors with the correct form of actions that the individual must have. This intervention usually uses a differential approach to reinforce a behavior that is taught instead of the undesirable behavior, this reinforcements can take variable forms of recognizable communications such as a vocalization or a manual sign. FCT works along with FBA ( Functional Behavior Assessment) to identify the communicative purpose underlying on the behavior describing it and identifying the consequences that led to it, this provides FCT with the causes of these behaviors allowing it to become really effective on the communicational skills, behavior playing, adaptive outcomes and a more directed elimination of the undesirable behaviors.