Page 2
Facilitated Mirroring: Building Perspective in Clients with Asperger Syndrome
Nan Gray Lester, M.S.
Instructions
I begin each Facilitated Mirroring group therapy session with a diagnostic explanation of the Key III. No matter how many times we review the Key III, my clients nod their heads with recognition, relief and a readiness to ascribe a personal experience related to these challenges. The Key III areas of difficulty include:
Executive Function Challenges
Broadly defined as a frontal lobe deficit that impairs mental flexibility and central coherence. Difficulties in this area may include:
- Multi-tasking, shifting focus and prioritizing
- Determining relevance in thought/action/objects and the perspective of others
- Narrow, perseverating interests
- Difficulty following instructions, particularly those involving sequence and chronology
- Lapses in word finding and thought continuity
- Inflexible adherence to literal language
- Difficulty with generalizing information
- Resistance to change, fixed routines and extreme difficulty coping with transitions
- Tactile: Over- or under-reactive to tactile stimuli (fabrics, foods), low or high pain tolerance
- Visual: Light sensitivity, diminished ocular control
- Auditory: Difficulty with auditory information processing, decoding sounds and hypersensitivity to auditory input
- Gustatory and Olfactory: Hyper- or hypo-sensitivity and reactivity regarding odors and taste
- Vestibular and Proprioceptive: Difficulties with posture, balance, joint stability, muscle strength and tone, motor planning and control, perception of depth and movement, and bi-lateral coordination
- Limited understanding of the perspective, emotions, intentions, motivations, behavior and reactions of others
- Impaired ability to read and provide non-verbal communication
- Impaired interpersonal communication skills, including reciprocity, topic content and relevance, conversational shifts and transitions
- Literal communication and atypical (pragmatic, pedantic) language
- Difficulty understanding and modeling appropriate social behavior
- Impaired understanding of interpersonal contexts and expectations
- Rigid expectations of others, strict adherence to rules, hypervigilance.
Sensory Integration Dysfunction (SID)
Challenges of the Central and Peripheral Nervous System in receiving and processing sensory information. These generally present as hyper- or hypo-sensitivity of the sensory processing system, including:
Social-Cognitive Deficit
Social Cognition is often referred to as Theory of Mind (ToM); however, I have experienced difficulty in communicating the abstract concept of ToM to my clients with Asperger Syndrome. I have had more success with the term Social-Cognitive Deficit. Many of my clients report this as being the most challenging aspect of living with AS. Difficulties in this area may include:
Teaching the Key III to clients is an exciting feature of Facilitated Mirroring. Intellectually understanding the aspects of the disability and how it manifests in their daily lives is a revelatory and perspective-building exercise for people with AS.
I understand that focusing on a client’s deficits goes against the principals of most strength-based psychotherapeutic modalities. However, it is important to remember that this process is not based on a normative model. These are the experiences of intelligent individuals who are fully aware that they are coping with the difficulties of living with a Pervasive Developmental Disability. They are looking for information and strategies on how to navigate more comfortably and successfully in the world. With Facilitated Mirroring, you will come to realize that despite the focus on diagnostics, teaching to the Key III is strength-based. It capitalizes on their intelligence and analytic ability while helping them to gain perspective on behavior. Self-regulation cannot be achieved without building self-awareness and perspective.
The next step for the therapist is to clarify the topical focus of the session. Interpersonal relationships, childhood experiences, and employment issues resemble the topics introduced within any group therapy structure. Within the model of Facilitated Mirroring, however, they are explored within the context of the disability and how it affects function. Topics may be predetermined by the therapist, agreed upon by the group at the end of the previous session, or established as a result of an impending or emerging issue on the part of one of the group members. If the latter is the case, I instruct my clients to contact me ahead of time so that I am prepared to establish the topic within the relevant frame of reference. In my experience, I do not advise an open-ended format or a call for topical ideas, as the options may overwhelm and dominate the group energy from the onset.
The framework for group sharing must be highly structured for the perspective building objectives of Facilitated Mirroring to occur. After introducing a topic, I will invite someone to share a relevant incident or experience. It is important that this individual be describing an event, and not an idea. The group then begins a round-robin sequence. Each member is asked to make observations on what Key III elements may be relevant in the story, their perception of how their fellow group member may have felt, and how they believe the incident may have been perceived by others around them. This exercise is an intellectualization of diagnostic references combined with perspective building observations; a process that you will find the group amazingly intrigued by and comfortable with over time.
The job of the therapist is to facilitate and help interpret meaningful reflections between the individual sharing and the other members of the group. Whether or not others can interject out of sequence or there is cross-sharing is a matter of a therapist’s individual comfort level with the group dynamic. I personally welcome deep discussion, but also keep a tight rein on the length of time that any one participant is allowed to share. Remember the communication difficulties inherent in the diagnosis of Asperger Syndrome. Once you become more familiar with the disorder and how it manifests, you will become more comfortable with the blunt style you may need to develop to meet the needs of your group.
There are many continuing themes in working with people with Asperger Syndrome. The two that I recognize as causing the deepest emotional scarring over time is the fear of making mistakes, particularly at work, school, or in social situations, and the subsequent humiliation of a public “meltdown” over the incident. The AS meltdown is described as having a near blackout quality. This experience, combined with the Key III diagnostic complications at play during the incident, often leave the individual with limited perspective of what actually occurred. They are rarely, if ever, given honest feedback about the incident by a neurotypical interpreter. In my experience, people with Asperger Syndrome have a tremendous need to process these incidents.
This is another important part of Facilitated Mirroring. You are working with people who often describe their life experience as feeling like an alien in their own culture. In fact, many of my clients report feeling more comfortable functioning in foreign countries, where it is already assumed that their behavior may be atypical. In processing these incidents, there is no room for nuance or subtlety; literal interpretation is absolutely critical. The triad model of Facilitated Mirroring is essential to the process. The perspective and validation offered by another individual with the same neurological challenges is tremendously supportive for the client, while becoming an invaluable therapeutic tool for the clinician.
Page 2