Adult Autism, Avoidance and Depression

In my work with adults on the spectrum I help adult clients take a look at a big theme: avoidance.

Avoidance is a theme, but not a constant pattern.  I've worked with many clients who, once they're interested in a task or problem, are the hardest workers I've ever known.

Yet these same clients may struggle with avoidance when it comes to everything from personal hygiene to buying Christmas presents.  It's puzzling to those around them, and even more puzzling to themselves.  Why can other people seem to "get it together" and "buckle down"?  Even clients who are functioning well are plagued by avoidance that causes anxiety and schedule disruption: a three-week project is avoided until the night before, then powered through at the last minute.  It's not as though the three weeks of avoidance were spent in blissful denial; rather, most clients describe an anxious, mental circling feeling that leaves them feeling dread.  So why not just approach the task earlier? Most determine that it must be a character failing.  What other reason could there be?

This avoidance may be depression in disguise.  Together, clients and I have come to understand that the autistic experience of depression often involves something other than the standard sadness we all associate with depression.  The autistic version of depression is dominated by apathy, and a pretty profound inertia that can make it hard to approach tasks or even move physically.  With our newer understanding of how depression's lowered dopamine levels impact motivation and drive, not just mood, (see http://www.sciencedaily.com/), this does make sense.  Still, recognizing depression when it doesn't necessarily involve a subjective sense of sadness, can be tricky. And that means that typical treatments that address sadness can be not only ineffective, but irrelevant.

More effective, you might think, is addressing the behavioral side of therapy.  The behaviors of getting up, showering, getting some exercise, etc, etc, etc.  Surely focusing a bit on these aspects of healthy functioning is not irrelevant, but it's no fix, either.  For clients on the spectrum, work is to be done for a purpose.  A demand for purposeless work, or what feels like purposeless work, can actually exacerbate avoidance symptoms.

In my experience, clients on the spectrum who are dealing with avoidance as a powerful symptom of depression, are dealing with a symptom whose roots are in feelings of meaninglessness.  Folks on the spectrum often find meaning through curiosity - once that door is closed, it's difficult to manage mood and motivation.  In fact, it may be that the "special interest" phenomenon we see with autistic adults is the just the behavioral manifestation of the mood-altering function of learning.  So treatment - at least short-term treatment - for depressive symptoms often involves learning of some sort.

If you have a loved one on the spectrum who is struggling with avoidance as a symptom of depression, it may help to know that many clients describe feeling confused and helpless as to why the problem of avoidance persists. While avoidance may at times look oppositional ("Why can't he just remember to take out the bins on Thursday? Why is it always my job?"), I rarely have found this to be the case.

Identifying the mood components of the behavior is crucial to understanding why the problem exists and how to begin solving for it.  As we all know, nagging, reminding, lists, threats and even real-world consequences often are of no help.

As I work with more and more adults on the spectrum over time, it seems to me that it is crucial that mood is carefully assessed.  This can be tricky - if the autistic adult cannot self-report sadness (either because it is not felt or not identified), and if many of the behavioral markers of depression are missing (no tearfulness, suicidality, missed work, diet changes, etc), depression can be, and is often, missed.  If it is, the behaviors that keep depressive symptoms at bay will be intractable, and psychotherapy will devolve into going in circles.  This can be especially demoralizing for couples.

If you or a loved one is looking for help, working with a clinician experienced in autism in adults is crucial, so that symptoms that present much differently in the autistic individual can be identified and treated.  And above all, so the autistic individual can have the experience of being seen.

Ticket-Punching: Couples on the Autism Spectrum

Many times in sessions with couples in which one partner is on the spectrum, much time is spent addressing an issue my wise Uncle Bob coined “ticket-punching”.

Here’s the definition:

Ticket-punching: v. an over-focus on schedules made, boxes checked and tasks accomplished, whereby the autistic adult is perceived as “missing the moment” and “more interested in lists than experiences”

This ticket-punching behavior, so I’m told, is especially prevalent during traveling.  Some adults on the spectrum may be great travel coordinators – almost too good at arranging tours, meals, destinations and activities.  His partner benefits greatly from this talent, of course: who wouldn’t love to have all these arrangements made competently, efficiently, and even cheaply?

But there does seem to be one problem.  The non-Aspie partner may complain of feeling alone on the trip, like the only one actually experiencing all these wonderfully scheduled happenings.  Out touring, she may look to her partner to share a smile of enjoyment, and find he’s busy consulting a map or phone, planning for the next event.  During dinner, she may move to share a taste of her dessert, only to find him more preoccupied with calculating the gratuity, the offered bite left untaken. At the end of the evening, she may find that they’re “sharing” a sunset – but instead of feeling companionship, she can sense he’s a million miles away.  It’s not a content quietness they’re enjoying, but a strained silence she’s enduring.

I often hear these clients ask Why?  Why go to all the trouble and expense, the time and the effort, only to stay so emotionally disconnected?  She may find trips less and less enjoyable because of the loneliness, or she may find the change of scenery a necessary distraction to home life.  Whatever the case, she’s often dissatisfied with the vacation, and the harder he works to make it a success, the less of a success it tends to be.

But here’s what I suspect.  I suspect he has difficulty enjoying the trip, (unless he’s actively engaged in learning).  I suspect that opportunities to sit and enjoy the scenery are either solitary activities for him, or if engaged in together, leave him baffled as to what to say or do.  I think ticket-punching gives him a role to fill that allows him to watch his partner have fun and enjoy herself – and this is often the closest he feels he can come to having fun himself.  He’s much more comfortable with setting the stage for his loved ones to enjoy themselves than he is with joining them emotionally.  If he cannot join, he logics, he will make himself useful.  And he often does.

From his perspective, really enjoying himself, getting lost in the moment, means he is likely to do something “wrong”.  Fun may mean embarrassment over that goofy laugh, or laughing too loud or too hard or too long or at the wrong time.  Being unselfconscious could mean losing pace with the tour group because he is caught up in marveling at the stars, or ordering dinner before the server has taken his drink request, or starting to talk excitedly before his friend is finished with his story or missing the cue he was supposed to pick up that now is the time for silence.  Letting go and participating could mean possibly ruining the trip, alienating fellow travelers, making a fool of himself.  The risk-benefit analysis points to sticking to what he’s good at: setting the stage for others, who don’t make such errors.

And here’s another benefit: adults on the spectrum can often enjoy the memory of happenings much more easily than they can enjoy those happenings in the moment.  Visiting a happening via memory is risk-free – it’s safer to have fun once you cannot fail.  It’s not that adults on the spectrum don’t feel – very deeply, in fact.  It’s that feeling, and expressing that feeling, has become associated with things like embarrassment and failure.  Those of us who can enjoy a trip without obsessing on expectations and possible points of social failure are so lucky.

So you may try starting small.  If you and your partner want to try to experience the moment, why not take it slow.  Expect that a vacation to the Galapagos Islands will bring with it an immense amount of anxiety; a short drive to the park or dinner.  He may try talking before thinking too much about it, and you may try accepting social errors as part of the desensitization process.  If you both try to be present emotionally, perhaps you’ll find that silence can be more comfortable than you thought.

Adults on the Spectrum: These are your Feet on Asperger's

When I first started working with adults on the spectrum there was no literature to refer to, and certainly no treatment guidelines.  It was a brand new frontier, and so exciting.  I haven’t lost that sense – that there’s an ever-expanding landscape of discovery when it comes to working with adults on the spectrum.  Part of the constant novelty lies in the complexity of the mind; our personalities and coping mechanisms emerge through a complicated interplay between environment and genetics.  Of course we all know this.  But most of us consider autism to be a strictly neurological disorder, with observable behavior manifestations.  After working with hundreds of adults, I’m beginning to have my doubts.


What emerges after working with so many adults on the spectrum are patterns.  These patterns reveal common threads between everything from client histories, to their private philosophical musings, to their choice of partners, to their sexuality, to the way they sit.  I’m not talking about anything near 100% consistency, of course.  But I am talking about unmistakable trends, the likes of which I’ve not seen in other populations.  I’ll be writing more about these trends in posts to come.

But for this short post I’d like to focus on one rather endearing trend: what adult clients do with their feet.  After seeing lots and lots of adults on the spectrum I couldn’t help but notice how they tend to sit.
Not all of them, mind you, just many more than I had ever seen when working with varied populations.

Since sitting in this manner is not socially sanctioned for adults (yes, even our sitting postures are guided many unwritten social mandates), it’s unusual to see adults, both men and women, sitting in this position.  Some of them let me take pictures of their feet.  I've got almost fifty of them! All the same position. It’s not a groundbreaking clinical observation, just a fun one, and one example of how people on the spectrum can transcend social expectations and teach us about ourselves.  Apparently sitting with your feet like this is really comfortable.  I’ve tried it now, and it made me remember how many comfortable things we give up when we enter the world of adulthood and social referencing.  The ability to be disconnected from social norms can cause problems - we hear lots about that - but it can also preserve behaviors that are timeless in their comfort and charm.

See our this post referenced on The Atlantic: http://www.theatlantic.com/health/

ASPERGER'S AND PARTNERS: THE 98 PERCENTER

In working with lots of couples in which one partner is on the spectrum, I cannot help but notice that many Aspies are coupled with highly relational people.  Perhaps this seems a common phenomenon – opposites do attract, after all.  But in these cases, partners seem more than just “opposites”. 

Partners of people on the spectrum often are more than just social – they’re often socially gifted.  These people can make friends with strangers in the checkout line, start up random conversations with people with seemingly no effort.  They’re often good with language – very good – and the path from their brain to their mouth seems short and straight (no pausing to find the perfect word, no searching for how to articulate a feeling).  When they’re angry, these partners are often even more articulate than usual – so quick with words that the Aspie cannot drum up a response before the partner is on to the next point.

I often refer to these non-Aspie partners as 98 Percenters.  These individuals are willing and able to do 98% of the work required to connect to another person.  Of course there are exceptions, but I find that the idea applies often.  So, who is the 98 Percenter?

• Often extroverted, or a socially extroverted introvert
• Can be emotionally labile – shifting and reactive moods
• Socially adept – can fit in with many different kinds of people
• Highly communicative of emotional states
• Can seem very angry one minute, then pick up the ringing phone and seem cheery
• Knows how to make people feel good
• Often skilled with remembering details about people’s lives
• Highly sensitive to others’ perceptions and judgments
• Quick to anger
• Prone to anxiety and/or depression
• Excellent at chit chat  (though s/he may not like it)
• Often interested in social justice (animal rights, etc)

It’s interesting that in sessions this highly communicative partner is often the person who answers my questions.  Sometimes they serve as a kind of bridge for the Aspie partner.  If I ask the Aspie partner a question that requires emotional analysis,  s/he will often look to the partner to answer it.  Of course this does make sense – it’s much more efficient, and the partner will be (perhaps) better at articulating the answer.  The truth is, the Aspie partner is just fine with answering – but allowing himself enough time to answer accurately would cause the conversation to lose its rhythm – and in general, this is a social no-no.

The 98 Percenter is often the kind of person who will “put herself out there” – risking rejection for the chance of connection.  S/he might reveal more about details Aspies consider to be personal (and therefore private) to casual friends. The 98 Percenter can be good at establishing what looks like instant intimacy.  I often hear from clients that “the party starts when she walks into the room”, or that people seem drawn to her.  It’s a sometimes dazzling level of attunement – the 98 Percenter can chit chat away while constantly monitoring how she’s being perceived and how others are feeling and perceiving.  That’s a lot of complexity, and it sure comes in handy.  However, when you’re 98% exposed, lots of things are revealed – including feelings like anger and resentment.  The Aspie partner experiences the lion’s share of this, and cannot usually understand why.

Sometimes this level of output comes at a price, and the 98 Percenter is exhausted after interacting – sometimes s/he has a hard time interacting at 50%.  In fact, if s/he’s not up to it, s/he may isolate until s/he can interact at her comfortable 98%.

Being a 98 Percenter sometimes means the individual is willing to do 98% of the work to connect to someone.  If there is an emotional space between two people, this person will just about fill it in order to connect – with emotional availability.  This works great for Aspie partners, in general, who seem less interested in letting it all hang out there – actually most of my Aspie clients seem more comfortable providing 2% - but an often pretty perfect 2%.  It seems like it should be a great system – because between the 98 Percenter and the complementary 2%, the whole emotional space should be filled, and partners should be able to feel connection.  But there’s a problem.

After a while, the 98 Percenter reports feeling tired and resentful.  What worked beautifully at first becomes mundane, then unsustainable.  As the 98 Percenter expresses relationship fatigue, then frustration, then desperation, the Aspie’s 2% seems unchanged.  This confounds, then enrages the 98 Percenter, who has felt willing to do so much work for so long, and is now looking for a little payback.

My opinion is that most of my Aspie clients are not unwilling to offer more than 2% emotional availability.  Under the surface they’re already offering more.  Most truly seem unschooled as to how to offer more (or in what form), and cannot tolerate much rejection.  S/he needs help understanding how and what and when to offer connection, and needs a recipe for success.

In typical relationships the percentages of emotional connection offered by partners differ, of course – but they do tend to wax and wane.  With Aspie relationships there’s less flexibility – but under the surface there’s also less variability on the part of the Aspie.  We can’t always strive to be a 50/50 relationship, but we can certainly find ways to limber up the system. And we do.

If you consider yourself to be a 98 Percenter, I really encourage you to think about how this ratio works (or worked) for you, and why.  Remember that it can translate to 98% of the emotional control and 98% of the emotional competence.  Finding ways to help your partner experiment with offering up more means you’ll need to give up some of that control and accept what is offered, as your Aspie partner experiments with the very scary process of revealing an imperfect self.

Adults with Asperger's and Building Self-Concept

How do adults on the spectrum build their self-image?

I've been thinking recently about this: how my clients have built and maintain self-concept. Most of us use relationships to some extent to gather information about ourselves and build self-image.  Ongoing relationships help maintain and develop self-image.  This is a healthy process (to the extent the relationships are healthy), and a normal part of development.

Development teaches us that the reciprocity of early relationships is the first step in building identity.  It is crucial to bonding and attachment - that seems obvious.  If an infant has an "attuned" caregiver, s/he learns basic trust; that is, if needs are expressed, they are largely met.  This starts immediately after birth: the infant cries, expressing distress.  The infant is then cared for appropriately (whether that means being fed, changed, rocked, etc).  Over time, these reciprocal experiences teach the infant, then toddler, then child, then adolescent, that relationships with people are sources of safety and nurturing.  We learn, as a by-product, that we are worth this safety and nurturing.

What happens, then, when the infant on the spectrum attempts to enter into this exchange? I can think of lots of ways the system may get disrupted.  For instance, many parents recall that their babies (later diagnosed with a spectrum disorder) were inconsolable - obviously physically uncomfortbale, but only able to be soothed sporadically and unpredictably.  Other parents recall babies who didn't cry at all - who seemed to lack the interest in communcation.  Rather than express the need for caregiving, many of these young ones turn to self-soothing.  In some ways they seem almost autonomous from the start - instead of wanting to be rocked to sleep, they rock themselves; instead of playing peek-a-boo with a parent, they flap their hands alone.

If a child is uncomfortable  in a way that cannot be interpreted or soothed by a caregiver, the consequences for attachment can be serious.  I'm not sure many of my clients have found relationships soothing, though they do crave them.  Many Aspie adults I see seem to have given up on bringing their distress to others for relief.  Of course this contributes to self-sufficiency, but also to loneliness, especially when life or feelings are overwhelming.  Their strategy, then, is to keep life and feelings from becoming overwhelming in the first place....leaving their partners wondering why they don't jump in to participate in stressful conversations or share emotional space with people they find unpredictable.

But think about it - what if you couldn't lean on others when the going gets tough?  What if you couldn't make your needs understood in order to get what you need?  What if, instead, you were scolded, mocked or rejected? This may sound dramatic, but think of the engineer who truly does not know how to clean a bathroom, or the programmer who always seems to say the wrong thing.  Over time these experiences teach the opposite of emotional reciprocity.  Rather, they teach that interactions and relationships are often sources of pain.

The first step for healing for adults on the spectrum, then, is often establishing a reciprocal relationship - with self.  I know this sounds corny, but it's true.  If I cannot establish a compassionate and attuned relationship with myself, I'm going to have a very difficult time communicating my needs to a partner.  And partners are often desperate to be of help.  When interdependency does not develop, they are left feeling ineffective, or worse, inadequate.  This contributes to the desperation and rage I see in sessions, where each partner feels shut out, but for very different reasons.

Back to reciprocal relationship with self.  We all must become "attuned caregivers" to our selves.  If we have missed this opportunity in childhood, for whatever the reason, we must develop this skill in adulthood.  The first step of self-care is noticing our internal states, so that we can begin to establish a routine of awareness of self.  For adults on the spectrum this is often new.

If you or your partner has difficulty finding solace in relationships, you're not alone.  You can learn to tune into your own emotional states and find healthy ways to meet your needs.  You can learn to articulate what you feel and ask for what you need.  Relationships with other human beings can become sources of support and love.  I think it's never too late to establish new ways of attaching to others.