For clinicians working with individuals who have an autism spectrum disorder (ASD), a key component to any therapy (group or individual) is helping these clients see the “big picture” when it comes to social situations, academic assignments, the need to do daily chores at home, reacting to the size of a problem and so on. Piecemeal representations, or focusing only on certain parts, do not allow one to see or understand the global context of a situation.
Many of our clients on the autism spectrum get stuck on these “parts” due to deficits in their executive functioning and their inability to see the big picture (Gestalt processing deficit). From a cognitive behavioral perspective, one may associate this with rigid thinking, which leads to an emotion of frustration and sometimes anger as a “negative automatic thought.” These negative automatic thoughts eat away at these clients, and they become so inflexible that they cannot move past the thought and get to the point where they can process the whole event.
On tasks that require holistic processing, such as reading a social situation, individuals with an ASD or other social learning challenge often don’t fare very well. They are poor social observers who get stuck in their negative automatic thoughts. Many times, past negative results have an impact on their overall cognitive sets about being social (“I have failed at being social in the past. Why will this be different?”). Both social and academic successes are reliant on a person’s ability to integrate separate “social pieces” into a cohesive understanding of a larger
task or social situation (the big picture).
The person must be in a mental state to allow flexibility in his or her processing of the event.
Think of it as a jigsaw puzzle. Kids with an ASD can see only one or two puzzle pieces at a time and get frustrated because they can’t see how the pieces they have — and see as the most important — will fit into the larger puzzle. These core deficits affect the therapeutic process and the time it will take in therapy to process and restructure one’s thinking about a particular situation.
Have you faced the following situation as a clinician? A parent comes into the session and wants to talk about a specific incident in which “Ben” (the client) had a huge reaction to something that occurred over the course of the week. Now you are asked to process this situation with Ben several days later, but Ben will get stuck on parts or details of the situation that really have nothing to do with the bigger picture. To Ben, those parts he is stuck on are critical aspects that others (in this case, his mother) have failed to see. This is not an issue of reality versus fantasy. Rather, it goes to the heart of Ben’s social processing abilities and how he interprets the importance of events that are all relative to his core deficits in executive functioning, Gestalt processing and theory of mind (being able to take the perspective of another person).
So, how can we help? What follows is a simple yet effective strategy that counselors can use to improve social processing. The goal would be to help clients who have social learning challenges to make their own social plans and understand the social context they are in.
Investigating the big picture
What we know about individuals on the autism spectrum is that many (but not all) are visual learners. Using visuals is key to helping these clients understand the social expectations of situations. Initiate what we call a “social task analysis” on a piece of paper, white board or napkin (if nothing else) by drawing or writing out the following “parts” to the whole situation your client is processing with you. This process is not meant to be hard or upsetting for children or clients. It should be done when they are in a state of relative calmness and open to processing what they are thinking about or something that occurred in the recent past.
Remember, social problem-solving interventions should not be used only to process something negative. These strategies can be used to process something the person is thinking about, something that may be causing the person stress or even when something positive has happened. In fact, initiating a social task analysis following a positive event may help these clients to recall that positive outcome the next time they are faced with similar situations.
The social task analysis should include the following steps:
a) Identify the context. This includes not only the place and time of the situation but also sets the social and behavioral expectations for that situation.
b) Write down the names of the individuals involved. This brings meaning to the people in the situation.
c) Identify the “tipping point” in the situation. This might be a social roadblock, problem or glitch faced by the people or it can be a positive turn of events. It merely signals that something has happened to affect the thoughts, feelings and actions of people in a given space.
d) Identify the thoughts, verbal expressions and feelings of those involved.
e) Draw out a “plan” for the situation if there is a roadblock the person needs to overcome. The fact of the matter is that there may not always be a solution right then and there. It is more important that clients learn how to create a plan or a sequence of steps to attempt as a means of overcoming roadblocks rather than knowing there is always a “right” or “wrong” outcome. Counselors might find it beneficial to make a plan A and a plan B with clients as a means of teaching cognitive and behavioral flexibility.
f) End by teaching clients to implement a reflection piece. Teaching clients (and their families) how to reflect back on a given situation is critical to developing positive episodic memories. This reflection time should be a learning opportunity that will help them the next time they face a similar roadblock.
When possible, and especially in school settings, leave some time for “behavioral rehearsal” of the possible scenarios that were discussed. I don’t think the students we are trying to teach social cognitive concepts to have enough opportunity to see themselves “be social,” so anytime a role-play can be performed, it will help them with their working memory of the situation as well as the motor planning aspect of all the social sequences. Research in this area of role-playing and video modeling certainly supports its use.
During your behavioral rehearsal, introduce some perspective-taking concepts by explaining the thoughts and feelings of people involved (and please start using the word “maybe”). For example, you may have the child or client verbally rehearse the following scenario: “Next time I see Joey, I will remember that he likes the Red Sox and maybe he will ask me about the Yankees. I will feel good because I asked him about something I know he likes. If he doesn’t ask me about the Yankees, that is OK too.”
This concept of “maybe” is important for our more rigid thinkers to understand. The use of the word “maybe” aims to create flexibility and is proactive because it does not allow these clients to create just one picture in their heads related to how things are “supposed to go.”
Helping clients on the autism spectrum to see the bigger picture will take time, patience and a variety of tools in the clinician’s toolbox. Setting small goals that enable improvements to be seen in this area is important because it will allow the counselor, the client and, in the case of children, the client’s parents to know that things are progressing in the right direction.
Chris Abildgaard is the director of the Social Learning Center in Wallingford, Conn. He is a nationally certified counselor, a nationally certified school psychologist and a licensed professional counselor with a specialization in autism spectrum disorders and social cognitive interventions. Through his clinical practice and professional interests, he has been exploring methods for integrating cognitive behavior therapy with other tools to improve executive functioning. Contact him at firstname.lastname@example.org.