Tuesday, December 3, 2013

The Outsourcing of Emotions: Adults on the Autism Spectrum

What gets repressed will be expressed...
not by you – but by your partner.

There’s this interesting phenomenon I notice amongst couples I work with.  It involves emotions, and how partners work together to manage unmanageable emotion loads.  They may not see it this way, but from my perspective it looks as though they are unconsciously dividing up and sharing emotions such that their partnership stays, although maybe uncomfortable, intact. 

As you probably know, lots of clients on the spectrum describe feeling “flat”, or emotionless.  They seem to have identified only two emotional states: undistrurbed and disturbed.  Distrubed emotional states are extremely uncomfortable and difficult to recover from, so, logically, many try not to get disturbed in the first place.

Between the Aspie client and his emotions is an extremely effective dam, and he feels little control over how wide, if at all, the floodgates are opened. While there may not be an accurate sense of what feelings actually lie on the other side of this dam, what is felt is a real dread of the size and intensity of these unknown emotions.  Clients seem to spend much of their time avoiding this dread, and occupying their interests and attention to this end.  They may spend time thickening the dam walls, by caking on layers of avoidance through distraction, compulsive working or even substance use.

This might work well, if only the emotions didn’t somehow leak out from beneath the dam, or spill over the top.  But, in fact, the dam does develop cracks. Minor cracks can bring anxiety and irritability, while major cracks can bring panic and apathy.   The great, nameless fear is that if the dam breaks, one might be engulfed, or even annihilated.  And since, when feelings leak out, they really do tend to be overwhelming, this theory gains credence over time.

In times where pressure mounts, the adult on the spectrum often employ one of two methods for emotion management – 1) he more frantically pursues his interests (because he’s increasingly desperate to distract from the pressure of mounting emotion), or 2) he provokes the emotion’s expression in his mate. I call this last tactic the outsourcing of emotions. It’s effective in the short-term, but can damage the attachment between partners.

What might this look like in everyday life? 

Say a family is attending a holiday party.  Let’s invite in our favorite hidden autistic adult, Joe. 

Joe and his wife (we’ll call her Jane) and two kids are preparing to leave for the event, and unspoken tension is high.  Joe is experiencing anxiety, but it’s a mindless kind of anxiety – he hasn’t really named the feeling, and therefore hasn’t had the opportunity to really solve for it.  What he does internally is a kind of disconnecting from the people around him.

Joe is on auto-pilot, and has decided the family should leave at 3:00 PM on the dot.  He fails to communicate this to anyone but himself, and instead imagines his family members know, or should know, about the deadline.  Of course, 3:00 o'clock comes, and 3:00 o'clock goes, and no one is ready to leave for the event.  Except Joe, that is.  He’s been alone waiting in the car for half an hour.

Once Joe can silently stew that his family members are not meeting expectations (of course there’s no way for them to meet expectations they don’t know exist!), he has a reason – a righteous reason! – for disconnecting.  Joe hasn’t learned how to rely on other people as sources of comfort; instead, they often feel to him like sources of danger.  Read on how this becomes a self-fulfilling prophecy, once the afternoon continues to degrade.

When finally Joe’s family members join him the car their emotional states have all arranged predictably: Joe is sullen and removed, Jane is frantically positive (trying to save the day from the inevitable), and the kids are becoming increasingly hyper and disorganized.  Once on the road, Joe begins driving with too much intensity, his jaw set and his gaze focused solely on the road.  When asked what’s bothering him, his reply is “nothing”, though various sources of stimuli are now crowding in on his consciousness – the noises, the sights, the chaos. Joe might truly believe at this point that his irritation is due to the missed deadline.

He may snap at the children, park too far away for his spouse’s taste, "sneak" an obvious glance at another woman – whatever the behavior, chances are he’ll continue until some unspoken line has been crossed.  Once it has, Jane becomes angry, and loses her temper.  She’s exhausted by the game they’re both playing, but unable to move differently in this very familiar dance.  “So many outings go this way,” she thinks.  “Why do I even try?”. 

Once Jane is angry, Joe can finally feel the sadness that has been fueling his behavior all along; and in this, he feels saner.  This seems so counterintuitive, doesn’t it?  But from Joe’s perspective, you see, the situation – and his reaction to it – now makes sense.  Joe finally feels like what he sees (his angry wife) has justified his internal state (anxious, excluded). And Jane has become the expresser of his angst; while he hangs back from the family, she has become irritable and overwhelmed.  Unconsciously, she has taken on his unbearable emotions.  At her own expense, she has served as an emotional surrogate of sorts.  Now Jane is feeling many of the feelings Joe had in the first place – Joe has outsourced his emotions.

The down side of this dynamic?   It is unconscious – Joe has not slowed down enough to identify, label, and communicate his distress (many clients don’t, because they feel unaware or ashamed that routine family outings cause them so much anxiety and confusion in the first place).  This outsourcing technique may save Joe the ego hit of having such struggles, but prevents his true solving of the problem.  What Joe actually learns, unconsciously, is that these states really are unbearable – that his spouse can bear them better, and will do so for him. 

Jane is also unconscious to this process, and is thus operating in the relationship in a way that damages her sense of self and sanity.  She may find, upon careful examination, that she has functioned this way in relationships before, especially in her family of origin (where we tend to learn these habits).  Perhaps she’s so good at intuiting the emotional states of others, that she confuses them with her own.

It’s so important to realize that there is no perpetrator here – Joe and Jane are both victims of this unconscious system. These roles and ways of transferring around unbearable emotion loads develop organically, and both members of the partnership play along.  Each feels as if s/he has no other options – he hasn’t found a way to deal effectively with his suffering without transferring it, and conveniently, she’s confused his suffering with her own, and therefore can't resist feeling it for him.

The fascinating part about this is that, in general, the outsourcing goes both ways.  There are plenty of times when the spouse does some outsourcing of her own – I hear about it in sessions when couples are discussing how much anxiety builds when, for example, guests come to the home.  In instances like these the roles are often reversed, with the Aspie partner working hard to absorb her unbearable levels of anxiety, and her neglecting to slow down long enough to truly manage her own emotional state.  The process might look very different on the surface, but a similar unconscious transfer of emotion is occurring.

Can we learn to operate differently in these situations?  Sometimes the patterns have been relived over and over, over years and years, maybe even passed on from generation to generation.  It seems so hopeless.  But it’s not.  The first step is to slow down and learn how to label emotion states.  I have many clients who cannot tell if they’re hungry, sad, tired or angry.  They skip over finding out, because they’re not good at it immediately, and because it takes time.  But it’s a crucial step to avoiding these mood management techniques that exploit relationships and erode our attachment.

(BTW- thank you to B.H. for encouraging me to get back to posting!)

Saturday, April 27, 2013

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.

Thursday, April 18, 2013

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.

Sunday, February 24, 2013

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/