One of the more humbling things about being a senior therapist is realizing the cases where we missed it because we didn’t have adequate training at the time or because the disorder hadn’t been adequately researched or named yet. We learn about something at a workshop or professional conference or in supervision and figuratively slap hand to forehead and think to ourselves “If only I had known . . .”.
Learning about the emerging research on adult Asperger Syndrome (AS) has caused me more than a few of those forehead-slaps over the past ten years. Although named by Hans Asperger in 1946, Asperger’s Syndrome didn’t get codified in the DSM until 1994. For many years thereafter it was seen as a childhood disorder; not something to consider when working with troubled and troubling adults. But looking back, I have to rethink how I worked with a number of cases that discouraged me at the time.
Some of those remembered sessions are poignant, indeed. I didn’t know what to say when a young woman asked me “How would you like playing second to a fruitfly? It’s like he’s having an affair! Once he’s with the flies, I may as well not exist!” I was equally flummoxed by a mom who plaintively asked, “How is it that my son with an IQ of 150 can remember the batting averages for every member of every team that has ever won the World Series but can’t remember his history assignment?” Then there was the man whose wife was ready to leave him because he never remembered to do household chores, regularly forgot to pick up their daughter at day care, had no friends of his own and alienated all of hers, in spite of being a brilliant and successful sculptor and crazy in love with her. I also have to wonder about the exceptionally bright teenager who flapped her hands and hummed whenever we got to something stressful – which was just about everything to do with other people.
Yes, I listened, interpreted, referred to resources, and encouraged all of these fine people. Yes, I found ways to connect and to genuinely like each one. I think, I hope, I was even helpful at times. But oh, how I wish I had known about Asperger Syndrome.
Fortunately, training in the treatment of adult AS is becoming more prevalent in our graduate programs and professional in-service opportunities. Fortunately, the diagnosis has now become part of professional discourse and the popular culture. And fortunately, books and materials are emerging to help the experienced therapist as well as the novice become familiar with diagnostic issues and treatment options.
In her book, Cognitive-Behavioral Therapy for Adult Asperger Syndrome, Valerie Gaus has made a major contribution to the conversation. She provides a practical overview of diagnostic cues as well as guidelines for evidence-based therapy. Using techniques of Cognitive-Behavioral Therapy (CBT), she has developed a comprehensive and effective model for intervening with adults with AS. Using case studies from her many years of research and practice, she offers the practicing clinician a readable and helpful window into work with this challenging population.
Gaus acknowledges that most of the research and practice in this area has been limited to children. Although it is now generally accepted that children don’t grow out of the disorder, understanding of the syndrome’s presentation in adulthood is still evolving. Because people with AS generally have normal to high intelligence and were often highly successful academically, they were more likely to be identified as shy, odd, or awkward as children, not as youngsters who needed specific help to learn the rules of the social world.
There is therefore a considerable population of adults with AS who were not diagnosed as children, who as adults experienced enough distress to seek therapy, and who continued to be misdiagnosed. Often highly anxious, underemployed, unable to make and sustain the friendships and romantic attachments they long for, they have been seen as treatment resistant, personality disordered, or depressed. Misdiagnosis has resulted in treatment that missed. When these patients show up in our consulting rooms now, says Gaus, discouragement and depression are often layered over the original problems of AS.
As with all diagnoses, adults with AS are a heterogeneous group. Gaus provides us with stories to highlight a variety of presentations. She then goes on to conceptualize mental health problems in adult AS as a result of difficulties processing information about self (emotional self-perception and regulation), about others (empathy, attention to and use of social cues), and about nonsocial information (planning, organizing, shifting attention, etc.). The result is poor social support and chronic stress that produce anxiety and depression. This construct is carefully explained with case examples to help the reader apply the concepts.
The remainder of the book is a careful utilization of CBT skills throughout the course of therapy. Gaus outlines intake issues and common problems identified by patients (depression, discomfort in social situations, frustration with inability to meet their own goals) as well as complaints by their families (anger outbursts, obsessions, procrastination, odd behavior, and poor self-care). She educates us about sexual problems that are rarely reported unless the therapist specifically asks. She describes interviewing strategies and what to look for in record review, and recommends formal testing instruments that she has found to be helpful. She then gives us a worksheet with which to formulate the case and choose evidence-based interventions. Finally, she describes a range of interventions that can increase a patient’s skills in addressing the core problems of AS.
Gaus’ frequent use of transcriptions of parts of sessions, anecdotes, and multiple case examples illustrate her ideas and keep us engaged. What could have been a ponderous academic clinical book is instead a readable and fascinating journey into the lives of those with AS and an opportunity to see an expert clinician at work.
While it is targeted to the practicing mental health clinician, the book would also be helpful to others who work with and relate to people with AS, including co-workers and supervisors, family members, and romantic partners. Clients with AS who are distrustful of authority or who are discouraged about therapy may find it an encouraging and exceptionally practical means of self-help.
Cognitive-Behavioral Therapy for Adult Asperger Syndrome
By Valerie Gaus
Guilford Press, 2007