Treatment, Love and Limits

I have treated so many adults on the spectrum. A few successfully.

And what I learned in school has proven barely relevant to the process.

Clients who come in trapped in the prison of their mind are in a fight for their lives. No clinician, no person, can ever win a battle to break into the fortress.

It's what the fortress is guarding against that needs addressing. Most clients I've met are dying of loneliness.

Most are guarding, full time, against a pervasive and nameless panic, or, in Sylvia Plath's words, the "o-gape of complete despair".

To imagine I might outsmart a client's mind, as it builds and rebuilds its walls of protection, is to have no understanding of my own limits.

I hope that, as we develop more and more complicated ways to name and talk about symptoms, we will eventually come to the simple understanding that to learn to give and receive love, after one has learned to live without it, is the bravest, most heroic journey.

It is the only journey. The rest is walking in circles.

Adults, Autism and Snipping

We’ve probably all heard about (or felt) imposter syndrome. In my work with adults on the spectrum, I notice that many of my clients struggle with some version of it. Even those who have achieved success in academic, professional, financial, and even social contexts struggle privately with the sense that none of it is real.

In contexts they’ve mastered they can appear socially adept (or so good at their jobs that social deficits are pardoned). But outside of a mastered context (whether the context is reddit or academia seems of little relevance), many struggle with something beyond social anxiety. I call it social panic.

How then are these adults able to function so well in these mastered contexts? It baffles both my clients and their loved ones. There are probably a number of ways to understand the discrepancy, and one way I describe it is via the idea of snipping.

Snipping is my way of describing how people with certain default styles cope with emotions that are beyond his or her capacity to handle. Under extreme stress, some of us snip the connections that bind us to parts of our own experience. It might be a foreign concept to someone who has never experienced it, but many of my clients recognize the phenomenon, though they’ve been unaware of it or unable to describe it.  

For instance, many of my clients are intellectually gifted. Their methods for processing reality may already differ a bit from those with less specialized brains. If the emotional load involved in processing reality in this way is too large to handle (as can be the case with those who perceive patterns and detail that remain out of awareness for most of us), adults on the spectrum have the option of snipping their awareness of the emotions. 

This is not necessarily a neurological reality (though I wouldn’t be surprised if it gets backed up by imagery sometime soon), but it is a way to describe the emotional shutdown so many clients experience, an experience they always describe as involuntary. I’m guessing if I had the option to do some snipping to avoid painful emotions I might rely heavily on that technique for managing everything from boredom to stress to grief.

Some clients snip not just their awareness of their emotions, but their awareness of their bodies, of time, of events taking place around them, of identity itself. Because of this snipping, they may be (in ways that seems almost genius – and maybe are) able to transcend typical limitations associated with the body (think of the busy programmer who forgets to eat or go to the bathroom), time (think of the musician who has been trying to master a piece for 12 hours straight), events around them (think of the cool mindedness of the non-reactive stance you’ve seen in the midst of conflict) and even identity (think of the adult who transcends typical limitations of gender, and even ego).

The snipping phenomenon can be a great tool, obviously, but like most coping styles, it appears to come with both benefits and costs. The benefits seem obvious: untethered from ego and emotion, my clients can often think in ways others can’t. Awareness of ego and emotion, especially, compete for attention and energy; divorced from these sources of internal resource depletion, clients on the spectrum can immerse themselves in music, programming, philosophy, etc. in ways that a more diversified brain might find out of reach. Clients often dazzle me with their perspectives and intellect.

The costs involved in snipping are sometimes immediate (such being unable to participate in a charged emotional situation that demands emotional engagement) and more often long-term (a life that runs like a machine but lacks vitality). Clients sometimes store negative emotions, such as fear and grief, in their bodies – digestive problems, sleep disturbances, jaw clenching, etc. – and even more often suffer symptoms such as difficulty harnessing attention and swings in motivation, as well as compulsive productivity alternating with periods of disassociation. Snipping can allow a bright person to block out fear so s/he can develop and express intelligence and think in ways that are exciting, but the fear has not truly been dealt with and transcended. It has been avoided, and - out of sight - it may even have grown.

The adult who has built not just coping mechanisms, but a life and a career (or even an identity) on a foundation of snipping maybe very wary of changing the system. I think this wariness is wise! When changing how one processes and interacts with reality, things tend to get shaken up. Who is to say it will be worth it in the end? A therapist who promises that it will be “worth it” is promising something she cannot know, and certainly cannot ensure. The client who ventures forth to change the snipping system must want something that s/he might not even be able to name. And s/he must have, to some extent, faced the reality that the system is breaking down, or is limited in ways that have come to be unacceptable.

When working with clients on the spectrum who have a snipped connection, I don’t make promises and I try to remain cognizant of the reality that I can’t sell the worth of knitting together that snipped connection. Realizing that a beautiful system of rationality and logic is limited or inadequate can be both painful and frightening. I have compassion for the pain of the realization, a respect for the difficulty of the path, and a willingness to walk with the client who dares to embark on the journey.

Adults on the Spectrum - and the Ted Bundy Question

I have heard – many times – from new clients, as they try to explain their predicament, sentences like this: 

"I am not like Ted Bundy – but I could be."

I used to be very puzzled by this – after all, I’d hear these proclamations from the very best of people. In fact, most of my adult clients could be described as conflict-avoidant, even in situations in which they feel threatened (rare in adulthood, maybe, but more common under the label of “bullying” in childhood). These clients are gentle, never cruel to animals, and certainly not the type to take pleasure in the suffering of any sentient being. Yet they come in so unsure of their basic nature, and they tell me this: “I am not Ted Bundy, but I don’t know why.”

A knee-jerk reaction in this case might lead a well-meaning friend or even therapist to brush aside such concerns as silly. But I think clients sense they are different – that though they don’t act in ways to deliberately harm others, the reasons behind their non-violent nature are different than the reasons shared by most. I think they may be right.

Many of us rely on a kind of shared emotional experience to guide their ethical behavior. It’s easy to imagine another’s fear, or pain, in the moment – it conjures up our own feelings of fear and pain, and that alone is enough to serve as a deterrent. But what if that kind of imagined experience wasn’t so automatic, or instant? This is the case for many clients. They find another path for managing their ethics in the moment – sometimes these look like the “rules” so often mentioned in ASD literature.

It’s the autistic adult’s wonderful workaround for a system (social, emotional) that’s not available and instant enough to guide ethical behavior. And this compensating system can really shine in moments when what’s ethical may cause another pain or discomfort – think of the last M.A.S.H. episode – so wedged in our minds because many of us could understand the horror of being faced with having to choose between the survival of many and the survival of an infant. There are times when ethics must be applied in ways that violate our sense of that automatic empathy we rely on for a moral compass function. So many clients on the spectrum can operate in settings (corporate, etc) in ways that transcend the emotional comfort of others, and even themselves, to do what’s right. This makes for less inclusion and social comfort for the client, but they endure (when many empaths do not).

As I’ve written before, I often find that adults on the spectrum are highly sensitive. But that doesn’t mean that the sensitivity is available in the moment, especially in social situations. Relying on ethical “rules” is a wonderful compensation, when immediacy is important. But this doesn’t mean that inside, many of the same feelings that move most of us aren’t alive and well.

So while I can understand why clients come in with an unsettled feeling that they could be Ted Bundy, I know that, via one system or another, they aren’t, and won’t be.

Adults on the Spectrum: The Emotion Exoskeleton

Emotions are funny things.  They can be a source of immense joy, as well as immense pain.  I think of them like a deck of cards we each have; trading positive cards can be a lot of fun. The healthier your relationships are (with others and yourself), the more enjoyable this trading becomes, the safer the game.

Like most things, how people experience emotions seems to run along a spectrum.  Some people feel emotions powerfully and readily.  Others feel emotions less readily, and when they do, the emotions are muted.  When I think of how my clients experience emotions, I think about what happens when emotions are unpredictable, indefinable, uncontrollable.

Many of us have a kind of internal “emotion skeleton” we use to arrange emotions; part of development involves a kind of coalescing of emotional experiences (between the individual and the environment, the individual and others and the individual and self).  Factors like experience, relationship modeling, attachment and physiology help us understand what emotions we hang close to the heart, what emotions are more peripheral.  This internal structure helps us organize and control emotion, such that over time we have a sense of solidity and control.

But sometimes this process of bone building is interrupted.  Emotions are too powerful or chaotic, or one’s environment requires a level of development not yet reached.  When this happens, the development of an internal mechanism for structure does not proceed as it should.  The internal skeleton needed to manage and understand emotions has not developed as it has needed to, leaving the individual feeling an internal sense of chaos.  It prevents a cause and effect kind of understanding of emotions from emerging, and leaves the individual vulnerable to emotional overload, and therefore a kind of mistrust of emotions.  Without that internal structure with which to organize emotions, feelings become hugely disorganizing, and even scary.

To cope with this phenomena, clients do a few things.  They may limit their access to emotions (“shutting down”)  in order to increase their sense of structure and control.  Keeping feelings out of awareness is one way to preserve what internal sense of calm and order there is.  Many clients erect exoskeletons of one sort or another. Examples are:

• Visualizing what’s to come
• Withdrawal
• Constant engagement in emotionless systems
• Substance abuse

One of the most common I hear about is visualizing what’s coming next – by having a vision for events, a kind of imagining of the future, many control to the extent they can the element of surprise (nothing ushers in emotions quite like surprise!).  This exoskeleton serves to shield from environmental triggers, and can work great, except that (by definition) an exoskeleton is not flexible.  Changes of plans can be jarring, cracks that allow emotions to flow in unexpectedly.  And when you’re depending on an exoskeleton to protect you from the emotional impact of your environment, it can feel scary to encounter those cracks.

Another kind of exoskeleton is withdrawal.  Clients talk about withdrawal in lots of ways; some withdraw into their own mind when potentially overwhelmed or bored, some withdraw physically into their homes or rooms.  Some use machines to withdraw – gaming systems, computers, etc. 

When in relationship with someone who has erected an exoskeleton, it can be confusing.  The individual might seem more interested in controlling the schedule than in connecting, or more motivated to game in the evenings than to talk.  I’ve seen so many couples struggling with this, seeming at war – one partner trying to pry the structure from the other’s hands in order to connect.  This always backfires of course – the structure is needed to make connecting even possible.  The more one partner pries, the harder the other clings to the structure.

Sometimes it seems couples have made an unconscious agreement with one another – one intends to provide the structure and benefit from the emotional life provided by the other. The other agrees to provide the emotional life for both, while benefitting from the structure provided by the other. This could be a great arrangement, and it is in theory. Usually, however, each partner actually craves more balance than this system provides. Most healthy relationships require a working skeleton on the part of both partners.

When addressing the challenges with personal emotions so many clients on the spectrum seem to face, one difficulty in particular arises: almost all of my clients have a well-developed understanding of emotions in theory. They’re all intelligent, so the idea they don’t know the difference between frustration and rage is a little insulting. What’s difficult is not theoretical knowledge – it’s recognizing emotions on a personal level. And here they do tend to struggle: if I’m hungry, I might be angry. If I’m sad, I might be depressed. If I’m anxious, I might be hungry. And so on. You can imagine what a challenge this is when, say, a partner is asking for emotional feedback on the fly.

But learning how to identify personal emotions is a process akin to learning to drive – no matter how bright, you can’t do it in one day. It involves a kind of brain conditioning, and starting with the basics is a must. That theoretical knowledge of emotions won’t help when you’re trying to figure out what you’re feeling in the moment; in fact, in can get in the way. So adults on the spectrum are faced with having to resist the temptation of traveling down a well-worn super efficient highway, and choose instead to travel down a rocky and erratic back road they’re unfamiliar with. This is tough to do when you’re a perfectionist!

If you were saddled with a big intellect, and also with difficulty identifying and understanding personal emotions, would you be able to set aside your ego and learn the basics?

It may be the only way to grow an emotion skeleton.

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!)