Narrative Therapy: A Psychotherapeutic Approach in the Treatment of Adolescents With Asperger's Disorder

Journal of Child and Adolescent Psychiatric Nursing,  Feb 2008  by Cashin, Andrew

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TOPIC: The conundrum of how to carry out psychotherapy with an adolescent whose primary currency of information exchange is visual as opposed to linguistic, and who is unable to develop a unified hase of knowledge and hence generalize concepts, has confronted many mental health nurses in their encounters with individuals with Asperger's disorder. At the currently estimated escalating rate of occurrence of 1 to every 100 individuals having an autism spectrum disorder, and the estimate that 80% of these people have average or above intelligence, it makes sense that Asperger's disorder is frequently encountered by child and adolescent mental health nurses. Asperger's disorder represents a different way of being in the world that is associated with a higher frequency of anxiety disorders and depression than experienced by neurotypical counterparts. The inherent concretization in the externalization techniques in narrative therapy provide a novelly successful approach to psychotherapy with people with Asperger's disorder and in many cases resolution of the conundrum.

PURPOSE: This paper considers the features of Asperger's disorder and its consonance with the techniques of narrative therapy, and utilizes a case example that shows the potential efficacy of the application of this established approach in a new context.

SOURCES: Contemporary literature on autism and narrative therapy.

CONCLUSIONS: The implication of the potential application of narrative therapy in psychotherapy with individuals with autism is raised.

Search terms: Autism, autistic disorder, Asperger's disorder, narrative therapy

Asperger's disorder is one of the three diagnoses that collectively make up what is currently considered to be the construct autism. Autism is a developmental neuropsychiatric disorder characterized by marked difference in the processing and storage style of information as compared to that experienced by those with typical development. The primary currency of information exchange for a person with autism is visual, as opposed to linguistic; and a unified base of knowledge about the world is not formed as part of the developmental process. As the majority of people in society do not have autism and can be considered neurotypical, a serious mismatch occurs in mainstream society between the ability of those with autism and the social demands placed upon them. As a consequence of this mismatch, those with autism often experience anxiety and depression to a pathological degree as part of the tensions of living. This emerges at transition periods and is often most intense as the person is engulfed in adolescence. A problem arises in working with a person with autism on these tensions of living when the tools we commonly use in psychotherapy are largely designed by, and for those with, typical development. How do you use words to ease tension with someone who is not a linguistic processor of information? Strangely enough, the answer may be found in a therapy designed to work on the stories individuals tell themselves about the world and their place in it. Although grounded firmly in the realm of linguistics, narrative therapy's focus on the here and now, and externalization techniques, are useful in the work with people with autism. Although instead of editing of stories the task is largely coconstruction of the story with the individual, the outcome can be dramatic as the person finds a scaffold to negotiate specific crisis-laden occurrences.

Asperger's Disorder

Autism is a behavioral diagnosis comprised of three diagnostic entities. The diagnostic entities that together make up autism as reported in the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) are autistic disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified (including atypical autism) (American Psychiatric Association, 2000). There is no clear distinction between the diagnostic constructs of autistic disorder and Asperger's disorder for a person that had single words by age 2 and communicative phrases by age 3, and has average or above intelligence. In any discussion of autistic disorder, or Asperger's disorder, the overall concept of autism is perhaps the most fruitful to employ as there is no difference in treatment or perceived cognitive processing style between each disorder (Eisenmajer, Prior, Leekam, et al., 1996).

The behaviors that characterize autism, and hence form the basis of a diagnosis, are clustered around impairment in three main areas popularly referred to as the triad of impairment (Scott, Clark, & Brody, 2000). This triad consists of impairment in communication, social skills, and cognitive and behavioral flexibility. Each category or area of impairment is dimensional, as opposed to categorical: It is not just about having a behavior that can be ticked off as present, but also the intensity and frequency of occurrence of the behavior (Berney, 2000). In fact there lies a continuum of impairment within each area of the triad based on the degree and frequency of behaviors, and this is complicated further by the fact that each person's distribution of impairment is individual and not necessarily uniform across each area of the triad (Wing, 1996). What is present is in the least, impairment that disrupts social and occupational functioning (American Psychiatric Association, 2000).